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Finding 575491 (2024-002)
Significant Deficiency 2024
Avivo
MN
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no...
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to 2023-2024, we only had one primary HUD contract that we were solely responsible for spending and contract timelines. With the addition of three more COC grants, with different, yet close together end dates, we needed to develop a more formalized process to ensure all expenses are billed to the correct contract for the correct dates. Avivo will implement oversight check-in meetings at least one month prior to each contract end and at least one more before final grant submissions. This meeting will include program leadership, RAA, Director of Housing Compliance, and our Contracts Accountant who oversees eLOCCS pulls. We will discuss all final expenditures and any upcoming expenses that may near the end of the grant term, including staff expenditures like mileage reimbursement. We will create an oversight document that highlights all areas to consider and breaks down roles and responsibilities to drive these meetings ongoingly. Accounting and program leadership will closely monitor spending via Papersave, credit card submission and through Paycom falls within the correct payment periods. Additionally, the RAA and Program Managers in the last quarter of the grant cycle, will meet monthly to work to resolve any outstanding rent balances and oversee any staff reimbursement or other charges that may need to be accounted for. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll & Lyssa Westling. Planned completion date for corrective action plan: December 2025
View Audit 365488 Questioned Costs: $1
Finding 575475 (2024-001)
Significant Deficiency 2024
Avivo
MN
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to document rental rate checks are occurring prior to entering into rental contract. Explanation of disagreement with audit finding: T...
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to document rental rate checks are occurring prior to entering into rental contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In March 2024, Avivo created a Rental Assistance Administrator (RAA) role to oversee all rental administration processes for our subsidy housing programs, including paperwork and compliance. The role developed over 2024 and was reviewed and reclassified from purely administrative to leadership and compliance in March 2025, after a year of development. With the new role, we have shifted responsibility off managers for final approval of documentation and have them focusing solely on programming and service provision. The RAA has created standardization across programs, ensures high levels of compliance, ensures no payments are sent without full, accurate documentation and helps to identify common errors early on and areas for training or support. To ensure the most accurate and complete paperwork is uploaded to our electronic health record, we are now submitting all subsidy paperwork through the electronic health system for review and approval. This solidified our process and eliminated managers creating their own processes. Switching to all approvals being electronic ensures that the most accurate and complete paperwork is available and in one place. RAA also approves and processes all rental payments from the service side and if paperwork is not approved, no payments will be released. Program Leadership, RAA and Director of Housing Operations meet bimonthly to review the program manual and policies overall to ensure most accurate policies and practices are reflected. We also updated our checklist cover sheets for all subsidy paperwork changes to reflect the changes from paper to electronic health record and have made several pieces of the subsidy paperwork process available to be completed electronically. In regards to rent reasonableness specifically, Program Leadership, RAA and Director of Housing Operations are planning two work sessions in late August and September, to review policies, current paperwork requirements and to plan additional training and supports for frontline staff to ensure full understanding of rent reasonableness and overall best practices. As part of this, we will review current paperwork and see if there are improvements that could be made, including making documentation fully electronic. We will also be looking at timelines around paperwork submission and sending out payments. Once it is determined what actions are the best solutions, managers will present changes and retrain on rent reasonableness and any other compliance improvements in team meetings in October 2025. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll, Program Director Planned completion date for corrective action plan: October 2025
Description of Finding: Activities Allowed or Unallowed - Significant Deficiency in Internal Controls Over Compliance and Noncompliance · Criteria: Salaries and wages and fringe benefits charged to awards must be supported by reports reflecting the distribution of activity for each employee whose co...
Description of Finding: Activities Allowed or Unallowed - Significant Deficiency in Internal Controls Over Compliance and Noncompliance · Criteria: Salaries and wages and fringe benefits charged to awards must be supported by reports reflecting the distribution of activity for each employee whose compensation is charged to the award. · Condition/Context: For 13 payroll transactions tested for allowability, the auditors noted that the rate charged to the grant differed from the rate the employee was paid. · Cause/Effect: The amount charged to the grant was based on the pay rate included on the employee's timesheet. The rate had not been appropriately updated on the timesheet, which resulted in an incorrect amount being charged to the grant. Statement of Concurrence or Nonconcurrence: Tribe agrees with the finding as stated by the auditors. Corrective Action: All grant awards were reviewed to reconcile salaries, wages and fringe benefits to the correct rate. Adjustments were made to multi-year awards, or updated Federal Financial Reports were prepared where appropriate. In October 2024, the tribe implemented a new payroll system, Paycom, that allows employees to code activity directly to an award. The payroll system allocates salary/wages and benefits based on the employee's current approved rate directly to the grant fund. Paycom will integrate with the Award Management module in the Tribe's new ERP system, Mission Gov beginning July 2025, for direct posting. Persons Responsible: Leslie Williams, Senior Vice President of Finance Wendy Collazo, Executive Director of Accounting - Tribal Government
Finding 575327 (2024-003)
Significant Deficiency 2024
Corrective Action Plan: The Organization has updated its internal review procedures to reflect the need to submit the quarterly Federal Financial Reports within the timeframe prescribed by the terms and conditions of the Federal award.
Corrective Action Plan: The Organization has updated its internal review procedures to reflect the need to submit the quarterly Federal Financial Reports within the timeframe prescribed by the terms and conditions of the Federal award.
U.S. Department of Health and Human Services 2024-001 Consolidated Health Centers – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization investigate the underlying cause of the error, and provide education or incorporate some sort of reconciliation or review process to ...
U.S. Department of Health and Human Services 2024-001 Consolidated Health Centers – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization investigate the underlying cause of the error, and provide education or incorporate some sort of reconciliation or review process to ensure sliding fee adjustments applied match the original determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will provide training to individuals involved with entering sliding fee discounts into EMR and will investigate other review or reconciliation procedures that could be incorporated to reduce risk. Name(s) of the contact person(s) responsible for corrective action: Jake Kuschke, CFO Planned completion date for corrective action plan: 12/31/25 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Jake Kuschke at 715-395-5386.
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chie...
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025 Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center...
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend that management hold additional training for front desk staff regarding the collection and verification of patient information for each patient. We also recommend enhancing your sliding fee status feature in your billing system to be completed for all patients to identify if the patient is insured, an application is pending, an application was received, an application was approved by finance for adjustment, and if an application was waived, to enable better tracking of the eligibility of each patient. We also recommend reviewing outstanding patient balances over 180 days to determine if follow up with a patient is required to collect the outstanding balance or to see if something has been collected by the front desk but not communicated to the finance team. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management agrees with the recommendations identified above. During April 2025, NHA started a project to review Self Pay balances with service dates prior to January 1, 2025 to follow up on why the balance is still outstanding. This would have caught the error identified above. In addition to this project, they have held additional trainings for front desk staff and will continue to do so and will continue to improve their methods of tracking patient eligibility. Name(s) of the contact person(s) responsible for corrective action: Doni Miller Planned completion date for corrective action plan: November 30, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Doni Miller, CEO at 419-720-7883.
Finding Number: 2024-001 ...
Finding Number: 2024-001 Equipment and Real Property Management (Internal Control and Compliance) Condition Our testing of the expenditures of Airport Improvement Program funds identified $192,000 of equipment purchased as part of the rehabilitation of the air traffic control tower. This equipment was recorded in the Authority's property records. However, the property records did not contain the required data elements noted above. Response/Planned Corrective Action We agree with the auditor’s findings and have already taken corrective measures to ensure compliance. Specifically, we conducted a full review of the Authority’s property records and updated the equipment entries associated with this project to include all required data elements. To strengthen compliance moving forward, we have created a Standard Operating Procedure (SOP) that mandates completion of all required data elements before any asset record is finalized. In addition, the SOP establishes a protocol for conducting periodic internal audits of property records to confirm accuracy, completeness, and adherence to federal requirements. These corrective actions have already been implemented, and the Authority will maintain ongoing oversight to prevent recurrence. Responsible Contact Person: Courtney K. Pittman Interim Executive Director, St. Johns County Airport Authority
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she...
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she did not have one of her weekly check stubs due to being out with Covid. The Specialist processed the following: She totaled three (3) check stubs, then divided by 4 with one being at zero. She then annualized. Upon further review, it was determined that the YTD included an additional pay week (which she stated that she was out with Covid). An interim will be completed with a Retroactive Agreement offered. 2. Income Verification Lola Garrett (please state tenant in audit for privacy act) -A student credit was given but failed to acquire the necessary source document. No retro necessary. 3. Late Reexaminations (4). Four reexaminations were processed late due to insufficient information provided. The Executive Director approved the late reexams to preserve and grow the lease-up rate (at 86%} prior to HUD's declaration of insufficient funds (May 2025} for the remaining calendar year of 2025. 4. Inspections - We did have one inspection overlooked at an elderly site since 2020. The other tenants within the complex did receive inspections including SEMAP. We are now utilizing the PIC report going forward (instead of in-house system) to prevent such an oversight again. Person Responsible: Jeff Trahan, Executive Director Anticipated Completion Date: July 14, 2025 Note: It is the Auditee's position that such an oversight constitutes a "deficiency" (oversight flaw) rather than a Significant Deficiency leading to a Material Weakness in Internal Control.
Corrective Action Plan Year Ended June 30, 2024 Identifying Number: 2024-001- Late Audit Reporting Finding: The audit, data collection form and reporting package for the Organization for the year ended June 30, 2024, should have been submitted to the Federal Audit Clearinghouse by March 31, 2025. Co...
Corrective Action Plan Year Ended June 30, 2024 Identifying Number: 2024-001- Late Audit Reporting Finding: The audit, data collection form and reporting package for the Organization for the year ended June 30, 2024, should have been submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Actions Planned or Taken: The Organization will schedule and complete future external audits in a manner that will allow timely reporting. Responsible Official: Rebecca Leininger, Executive Director Anticipated Completion Date: March 31, 2026
Finding 574901 (2024-005)
Significant Deficiency 2024
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognit...
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognition of expenses on the SEFA and documentation standards of the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program.
View Audit 365155 Questioned Costs: $1
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
Finding 574705 (2024-002)
Significant Deficiency 2024
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the service...
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the services of McCright & Associates LLC, a reputable HQS servicing company, to assist with rent reasonableness requirements. McCright now conducts all rent reasonableness comparables for all new units and staff confirm that a copy is stored in the participant file. Staff believe that with the implementation of these procedures appropriate steps have been taken to address this concern
Finding 574704 (2024-001)
Significant Deficiency 2024
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include d...
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with EIV requirements. Additionally, staff have been in contact with their software provider about system enhancements such as the software producing a warning/error if an employee attempts to process an EIV reexamination without updating the EIV date. Such enhancements would further help to ensure compliance with federal program requirements. Staff have also been attending training to ensure sufficient knowledge of program EIV requirements. Staff believe these efforts should address this concern.
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be c...
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be combined to identify students who were awarded the subsidized loan in error. These reports will be reviewed after each add/drop period. Management has made a request to our vendor to create a special report that will capture this data in a more time efficient manner. Person Responsible for Corrective Action Plan: Darla Hopper, VP of Enrollment Management Anticipated Date of Completion: 09/30/2025
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selecte...
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selected for testing Friends of Family Health Center incorrectly applied the discount or were put in the incorrect category based on income and family size. Response One error in calculating a patient’s income with 40 others is a minor 2.5% error margin. FOFHC will have a quarterly training course on how to properly use the various income level tables provided to the front office staff. Responsible Party Dawn Ta, CFO Estimated Completion Date December 31, 2025
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all ...
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all vendors working on projects funded by federal grant dollars.
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: The AHA Director of Assisted Housing and the Senior Housing Inspector are conducting monthly reviews of inspection reports to identify deficiencies and ensure inspections extensions are completed on time. This program management process will continue on an ongoing basis. Additionally, we have hired an additional inspector to help meet inspection deadlines and improve overall timeliness. Anticipated Completion Date: Ongoing
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.
2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being ...
2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being sought. A Procurement policy has been obtained from another county to review. It is the intent of the county to prepare its own "Procurement Policy" during a policy work session, coming up this fall. Treasurer Anderson and Clerk Freese also toll a 2-day Procurement training put on by the Federal Grants Training Program this summer. In the meantime, the county will continue to follow all federal regulations for every grant we receive as per each particular project dictates.
Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to as...
Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to assist with audit preparation. This was in addition to $30,000 set aside in the county treasurer's budget for audit consulting. The county commissioners hired an individual in September 2024. That individual left employement with the county in November 2024 and the position was not refilled through the end of fiscal year 2025. The remainder of the FY2024 audit preparation was completed in-house. Due to reductions in revenue and budget constraints, both the $100,000 allocation for a new employee and the $30,000 for consulting services were cut from the commissioners' and treasurer's budgets, so the county is pivoting on audit preparation resposibilities and expanding the number of in-house employees working on different facets of the preparation. With the exception of the CPA that was on staff for two months, the rest of the finance staff has been stable for at least two years and have grown in their knowledge of county finances. We are utilizing 6-7 different staff members on parallel tasks with oversight and assistance from the county treasurer and clerk. We are confident that the audit preparation for FY2025 will be completed months earlier such that trial balances and supporting documentation will be available to our auditors in time to meet the federal submission deadline.
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
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