Corrective Action Plans

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Responsible Contact Person(s): Gena Boyle, Deputy Commissioner for Policy and Administration Angela Morse, Director of Benefit Programs Corrective Action Planned: Proposed changes to the Code of Virginia will be submitted for the next General Assembly session's consideration. Estimated Completion Da...
Responsible Contact Person(s): Gena Boyle, Deputy Commissioner for Policy and Administration Angela Morse, Director of Benefit Programs Corrective Action Planned: Proposed changes to the Code of Virginia will be submitted for the next General Assembly session's consideration. Estimated Completion Date: 7/1/2024
Recommendation: We recommend that the Authority reviews its internal controls over HAP abatement to ensure units that do not meet HQS are abated for the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to ...
Recommendation: We recommend that the Authority reviews its internal controls over HAP abatement to ensure units that do not meet HQS are abated for the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Along with the restructuring of the Assisted Housing Department to add additional management positions, implement comprehensive standard operating procedures and training, HHA will ensure that Housing Assistance Payments (HAP) is properly abated on all units under abatement. Abatement quality control measures will be implemented using comprehensive standard operating procedures, which will include clearly defined eligibility processes and enhanced quality control measures. HHA will also contract with an HCV consultant to provide additional training to the HCV management team. HHA is committed to ensuring that all employees have proper training in all components of the HCV program Name(s) of the contact person(s) responsible for corrective action: Turkessa Coleman Lacey, Deputy Executive Director Carmisia Danson Woods, Interim Assisted Housing Director Planned completion date for corrective action plan: Complete and on-going If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Carmisia Danson Woods, Interim Assisted Housing Director at 256-532-5672.
Recommendation: We recommend that the Authority reviews its internal controls over obtaining and maintaining income and expense tenant file documentation to ensure compliance with eligibility requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Recommendation: We recommend that the Authority reviews its internal controls over obtaining and maintaining income and expense tenant file documentation to ensure compliance with eligibility requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Huntsville Housing Authority (HHA) is restructuring the Assisted Housing Department to add additional management positions, implement comprehensive standard operating procedures, which will include clearly defined eligibility processes and enhanced quality control measures, to include, provisions to appropriately determine dependent allowances. Management will conduct oversight of key functions, data entry, and maintain a consistent review of regulatory compliance. Management will complete more targeted and a higher number of internal quality control audits. Additionally, HHA will increase staff training on income, assets, expenses, deductions and rent calculations. This approach will also include obtaining and maintaining the correct backup and support documentation. HHA will also contract with a Housing Choice Voucher (HCV) consultant to provide additional training to the Assisted Housing management team. HHA is committed to ensuring that all employees have proper training in all components of the HCV program Name(s) of the contact person(s) responsible for corrective action: Turkessa Coleman Lacey, Deputy Executive Director
Reference Number: 2022-002 Compliance Requirement: Reporting Type of Finding: Internal Control and Compliance Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Assistance Listing Number(s) and Title: 84.425 ? Higher Education Emergency Relief Fund(HEERF) Fe...
Reference Number: 2022-002 Compliance Requirement: Reporting Type of Finding: Internal Control and Compliance Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Assistance Listing Number(s) and Title: 84.425 ? Higher Education Emergency Relief Fund(HEERF) Federal Awarding Agency: U.S. Department of Education Bishop State has reviewed and recognized the needed changes to be put into place to ensure timely reporting and accurate record keeping for all reported data. Bishop State has the Restricted accountant complete the quarterly and annual HEERF reports and file all data according to the report in an organized and methodical method. Once the Restricted Accountant completes the report the Chief Financial Officer and/or Director of Accounting will review the reports and backup data for approval. Once the reports are approved they are handed over to the Grants Administrator for filing on-line with the Department of Education via the HEERF site. This audit finding is a duplicate to the audit finding 2021-005 from the previous fiscal year. The 2022 fiscal year was 75% of the way over at the time the prior year audit finding was presented to Bishop State Community College. At the point of notification all quarterly and annual reports were filed according to HEERF uniform guidance. No other corrective action had to be taken in the 2022 fiscal year as all other uniform reporting guidance was met for the 2022 audit. Anticipated Completion Date: October 2022. Contact Person: Jessica Davis, Chief Financial Officer
Responsible Contact Person(s): Annette Sherrill, Assistant Superintendent for Budget & Finance Geri Hayes, Director of Finance Dhaval Patel, General Ledger Manager Corrective Action Planned: Staff are actively working on ensuring that FFATA data submitted is accurate. Additional information related...
Responsible Contact Person(s): Annette Sherrill, Assistant Superintendent for Budget & Finance Geri Hayes, Director of Finance Dhaval Patel, General Ledger Manager Corrective Action Planned: Staff are actively working on ensuring that FFATA data submitted is accurate. Additional information related UEI numbers is being collected to ensure that data submitted does not encounter errors among submission. Staff have also attended webinars and are performing reconciliations between financial systems. Estimated Completion Date: 12/31/2023
Responsible Contact Person(s): Angela Wright, Director of Finance Corrective Action Planned: The Director of Finance has provided additional training to staff and is performing a detailed review of all reports to ensure accuracy. Estimated Completion Date: 2/15/2023
Responsible Contact Person(s): Angela Wright, Director of Finance Corrective Action Planned: The Director of Finance has provided additional training to staff and is performing a detailed review of all reports to ensure accuracy. Estimated Completion Date: 2/15/2023
Responsible Contact Person(s): Timothy O. Kestner, EIA Director Corrective Action Planned: EIA Management has developed a reporting schedule outlining the frequency, responsible party, and due date of all required reports. This is a collaborative effort across several business units; therefore, pol...
Responsible Contact Person(s): Timothy O. Kestner, EIA Director Corrective Action Planned: EIA Management has developed a reporting schedule outlining the frequency, responsible party, and due date of all required reports. This is a collaborative effort across several business units; therefore, policies and procedures have been updated and communicated to all users to ensure compliance. Estimated Completion Date: 2/15/2023
Responsible Contact Person(s): Angela Wright, Director of Finance Susan Landis, Director of Unemployment Insurance David Clark, Information Security Officer Corrective Action Planned: Finance Management has strengthened existing processes especially for removing terminated employees? access from the...
Responsible Contact Person(s): Angela Wright, Director of Finance Susan Landis, Director of Unemployment Insurance David Clark, Information Security Officer Corrective Action Planned: Finance Management has strengthened existing processes especially for removing terminated employees? access from the internal financial system. Unemployment Insurance Management is in the process of developing a benefit system report to be used by the system owner to review and update current staff access and to evaluate new user access levels. The ISO will work with System Owners to ensure annual access reviews are completed. Estimated Completion Date: 6/30/2023
Responsible Contact Person(s): David Portner, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Fed...
Responsible Contact Person(s): David Portner, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 2/15/2023
Responsible Contact Person(s): David Portner, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Fed...
Responsible Contact Person(s): David Portner, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under ?2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled ?Applicable Management Contacts for Findings and Questioned Costs? to request the corrective action planned from the applicable entity. Estimated Completion Date: 4/30/2023
Responsible Contact Person(s): Paula Garrett, WIC Director Corrective Action Planned: The Remote Services Policy was updated and sent to local agency staff on January 21st. The updated policy included clarifying information about scanning in the affidavit so it is viewable in the record. An additi...
Responsible Contact Person(s): Paula Garrett, WIC Director Corrective Action Planned: The Remote Services Policy was updated and sent to local agency staff on January 21st. The updated policy included clarifying information about scanning in the affidavit so it is viewable in the record. An additional update to the policy will include a requirement for documentation as to why the affidavit is needed. Once in-person services resume, the normal policies and procedures for required affidavits will resume. Estimated Completion Date: 8/31/2023
Responsible Contact Person(s): Lisa Hawkins, Director - Information Technology Business Administration Corrective Action Planned: DSS has 15 applications that are in active oversight, IT Business Administration is in receipt of 14 of the 15 required SOC reports, the final SOC report is due at the e...
Responsible Contact Person(s): Lisa Hawkins, Director - Information Technology Business Administration Corrective Action Planned: DSS has 15 applications that are in active oversight, IT Business Administration is in receipt of 14 of the 15 required SOC reports, the final SOC report is due at the end of Q1 2023. Estimated Completion Date: 2/1/2023
2022-001 INADEQUATE SEGREGATION OF DUTIES Actions Planned ? The Authority is not in position to hire additional staff members for the sole purpose of eliminating the ?segregation of duties? finding from our audit. The Airport Office Administrator communicates with the Executive Director and com...
2022-001 INADEQUATE SEGREGATION OF DUTIES Actions Planned ? The Authority is not in position to hire additional staff members for the sole purpose of eliminating the ?segregation of duties? finding from our audit. The Airport Office Administrator communicates with the Executive Director and commission members regarding all major account transactions, including the recording of recurring and non-recurring journal entry adjustments. The commission meets monthly and closely monitors the financial information provided to them. Official Responsible ? Airport Office Administrator Planned Completion Date ? On-going monitoring Disagreement with Finding ? None ? The Authority concurs with the finding. Plan to Monitor ? The Authority is aware of the situation and will monitor, as it deems appropriate. Monitoring will include commission member oversight for the interim and year-end reporting.
AGING CLUSTER ? Assistance Listing No. 93.AGING Recommendation: We recommend the Council review its payroll procedures over hourly employees to ensure all hours are properly accounted for by pay code in the final payroll. Explanation of disagreement with audit finding: There is no disagreement with ...
AGING CLUSTER ? Assistance Listing No. 93.AGING Recommendation: We recommend the Council review its payroll procedures over hourly employees to ensure all hours are properly accounted for by pay code in the final payroll. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal staff will review timesheet formats and search for possible improvements to the existing templates. Since this incident occurred, the Council has split the former Fiscal Coordinator position into two separate roles. This allows each employee to spend additional time on a fewer number of employees during payroll and review each timesheet with a high level of detail. Fiscal staff will continue to focus on precautions to reduce risk of error and employees will be encouraged to review their paystubs after each pay period. Name(s) of the contact person(s) responsible for corrective action: Becky Walter, Fiscal Manager Planned completion date for corrective action plan: December 31, 2023
Community Development Block Grants ? Assistance Listing No. 14.228 Recommendation: We recommend that the Council record federal expenditures on the SEFA under the program in the year upon which the loan disbursement occurs. Explanation of disagreement with audit finding: There is no disagreement wit...
Community Development Block Grants ? Assistance Listing No. 14.228 Recommendation: We recommend that the Council record federal expenditures on the SEFA under the program in the year upon which the loan disbursement occurs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Council has revised their procedures so that loan disbursements will be recorded on the SEFA in the year in which they are disbursed. Name(s) of the contact person(s) responsible for corrective action: Anita Cameron, NLF Director, and Becky Walter, Fiscal Manager Planned completion date for corrective action plan: December 31, 2023
Community Development Block Grants ? Assistance Listing No. 14.228 Recommendation: We recommend preparing the required reports under the CDBG program to be ready for uploading to the portal once it is accessible to ensure reporting requirements are met. Explanation of disagreement with audit finding...
Community Development Block Grants ? Assistance Listing No. 14.228 Recommendation: We recommend preparing the required reports under the CDBG program to be ready for uploading to the portal once it is accessible to ensure reporting requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Program Director will work with the Fiscal Office to ensure all reporting requirements are met prior to the deadline, regardless of ability to submit. This plan will ensure past, current, and future reporting requirements are met. Name(s) of the contact person(s) responsible for corrective action: Anita Cameron, NLF Director and Becky Walter, Fiscal Manager Planned completion date for corrective action plan: December 31, 2023
2022-003 Health Centers Cluster ? Assistance Listing No. 93.224 and 93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the col...
2022-003 Health Centers Cluster ? Assistance Listing No. 93.224 and 93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Expired sliding fee application Design, implement, and review a monthly report to ensure that the appropriate employees are making the Financial Assistance (FA) and Sliding Fee Discount Program adjustments. Every 2 months ? internal audits of FA and Self Pay patient accounts will be completed and documented. Additional training will be completed and documented for all Revenue Cycle Team members. We will review Discount Program along with Financial Assistance policies and procedures and discuss our financial policy related to ? Sliding Fee Scale. 2) Incorrectly assigned discount due to brief variation in sliding fee tables to expand the number of patients eligible to receive discounts. Heartland?s policies and procedures clearly reflect that the sliding fee scale discount program will only be extended to eligible patients up to 200% of the federal poverty guidelines. The Revenue Cycle Manager and CFO will ensure on a every 2-month basis that no slides will be given to ineligible patients based on income and family size. This monthly review will be documented, approved, and filed by fiscal year. Name(s) of the contact person(s) responsible for corrective action: Michael Cohlman, CFO and Katie Saucedo, Revenue Cycle Manager Planned completion date for corrective action plan: 4/1/23
Finding 35377 (2022-005)
Significant Deficiency 2022
ELIGIBILITY Recommendation: The County should implement additional procedures to provide reasonable assurance that necessary documentation is properly input in MAXIS. Case file reviews should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit findin...
ELIGIBILITY Recommendation: The County should implement additional procedures to provide reasonable assurance that necessary documentation is properly input in MAXIS. Case file reviews should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: LoAnn Shepard, Eligibility Supervisor Planned completion date for corrective action plan: December 31, 2023
Finding 35373 (2022-001)
Significant Deficiency 2022
We agree with the finding and recommendation and recognize that this is a repeat finding from the prior year audit. Transactions in Periods 2 and 3 PRF reports were reported prior to the conclusion of this prior year audit. We implemented new processes in response to the prior year finding and rec...
We agree with the finding and recommendation and recognize that this is a repeat finding from the prior year audit. Transactions in Periods 2 and 3 PRF reports were reported prior to the conclusion of this prior year audit. We implemented new processes in response to the prior year finding and recommendation, and claims in Period 4 PRF report were reported based on actual expenditures. Contact person responsible for corrective action: David McGrew, CFO, San Mateo Medical Center. Anticipated completion date: September 2022.
2022-004 Innovative Approaches to Literacy; Full-Service Community Schools; and Promise Neighborhoods ? Assistance Listing No. 84.215J Recommendation: We recommend that the organization review their policies and procedures surrounding federal grants administration and ensure a review process is in p...
2022-004 Innovative Approaches to Literacy; Full-Service Community Schools; and Promise Neighborhoods ? Assistance Listing No. 84.215J Recommendation: We recommend that the organization review their policies and procedures surrounding federal grants administration and ensure a review process is in place to ensure that all necessary compliance requirements are met and the organization?s records are complete to support all reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Grant Manager utilizes fluxx grant management system which documents all submission of grant reports and maintains documentation support. Finance as well has organized a filing system organized by department and then list accounting function as well as report assistance for grants. Name of the contact person responsible for corrective action: Anthony Conley Grant Manager / Compliance Specialist Planned completion date for corrective action plan: 12/31/2023
2022-002 Segregation of Duties Recommendation: The organization should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including the number of internal staff), to determine whether additional controls over the financial reporti...
2022-002 Segregation of Duties Recommendation: The organization should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including the number of internal staff), to determine whether additional controls over the financial reporting function can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Assemble a finance team and identify finance function roles for staffing and personnel. Name of the contact person responsible for corrective action: Sam Jones, Outsourced CFO Planned completion date for corrective action plan: 12/31/2023
2022-001 Financial Statement Preparation and Adjusting Journal Entries Recommendation: The organization should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of annual financial s...
2022-001 Financial Statement Preparation and Adjusting Journal Entries Recommendation: The organization should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of annual financial statements can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Assemble an accounting team with designated roles including expert experience and perform policy written period ending procedures on time to assure accuracy in the financial. Name of the contact person responsible for corrective action: Sam Jones, Outsourced CFO Planned completion date for corrective action plan: 12/31/2023
Finding 2022-002 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, su...
Finding 2022-002 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such that the MCHS system of controls now extend to MMC-Dickinson. Specifically with these changes, grant accounting duties are also transitioning to the MCHS grant accounting team which extends MCHS system of controls over grant accounting to MMC-Dickinson to ensure accurate and timely completion of the Schedule. Proposed Completion Date: December 31, 2023
Finding 2022-003 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such...
Finding 2022-003 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such that the MCHS system of controls now extend to MMC-Dickinson. With these changes, the MCHS Treasury department will include MMC-Dickinson and this debt in their system of controls and processes which includes monitoring the debt and related reserve accounts for compliance with debt service reserve requirements. Proposed Completion Date: December 31, 2023
Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work wa...
Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work was not completed for several months. Although expenses were overstated in the portal, the grant was not overcharged as lower expenses reported for physician compensation costs would have been replaced by increasing the amount related to additional eligible lost revenues. Management will implement review procedures for eligible physician compensation costs to ensure expenditures to the portal are accurate. Proposed Completion Date: December 31, 2023
View Audit 24187 Questioned Costs: $1
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