Corrective Action Plans

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Corrective Action Plan CY Findings: 2024 -001 U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services, Division of Social Services Program Name: DSS Crosscutting (State) Supplemental Nutrition Assistance Program AL#10.561 CY Finding 2024-001 Signi...
Corrective Action Plan CY Findings: 2024 -001 U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services, Division of Social Services Program Name: DSS Crosscutting (State) Supplemental Nutrition Assistance Program AL#10.561 CY Finding 2024-001 Significant Deficiency over Internal Controls Name of Contact Person: Melissa McDaniels, SIU Supervisor Corrective Action/Management’s Response: Our prior process for completing the DSS-1682 was not fully aligned with federal policy and guidelines. During the audit a DSS-1682 form with a February date of discovery entered into NC Fast was found unsigned by supervisor. This form was reviewed and approved by the new supervisor in July when brought to her attention. Prior to completing the approval, clarity was sought from our state partner. Guidance was provided to SIU Supervisor (Melissa McDaniels) concerning processing the DSS-1682 accurately according to policy 800.06 D.7(Katie White 7/19/24). Program staff (SIU) was retrained on the DSS-1682. A reminder of state policy and the proper way to complete DSS-1682 was sent to staff on 8/9/2024 by SIU Supervisor Melissa McDaniels. These measures are in place to prevent future errors with the DSS-1682 form. Prior supervisors of SIU (Jessica Murphy and Kathy Alston) were asked to provide training to the new supervisor and Business Officer to ensure all agency practices align with DSS policy. All SIU dates of Discovery are being reviewed and verified by staff when completing 2nd reviews. Proposed Completion Date: 8/9/2024
The Payroll Internal Control issue was procedural and did not impact the financials or cost allocation. The Organization will address and resolve this procedural issue through a review and retraining of procedures, an audit of records, and ongoing monitoring. ...
The Payroll Internal Control issue was procedural and did not impact the financials or cost allocation. The Organization will address and resolve this procedural issue through a review and retraining of procedures, an audit of records, and ongoing monitoring. 1. Update Procedures, Documentation, and Retrain All Payroll staff to Protocols: The Payroll 2024/2025 Internal Controls memo and Payroll Desk Manual will be revised to clearly detail the step-by-step procedures that Payroll personnel must follow for staff timecard submissions. The documentation includes the approval process by managers or their delegates, handling of missing approvals, and the review process conducted by Finance management. The documentation will also emphasize the procedural component and collaboration with human resources regarding the corrective actions required for managers who are not compliant with the procedures. These updates will ensure a smooth completion of the bi-monthly payroll cycle and facilitate monthly reviews. All payroll staff and the controller will undergo retraining in this process. New payroll staff will receive training in accordance with these expectations. Planned date of completion: 1/31/2025 2. Timecard Audit: Payroll will audit timecards for the period from July 1, 2024, to November 30, 2024. The audit aims to identify timecards that require approval from both employees and management. Any timecards that need approval will be addressed using the backup documentation required by the agency's internal control procedures. Planned date of completion: 1/31/2025 3. Ongoing Monitoring Plan: After each pay period, an audit report will be generated that includes the details of timecards, specifically identifying those paid through UKG that are missing approvals. The analyst will ensure that documentation is obtained from the employee's manager, confirming approval of staff time for each identified missing approval. These reports will be reviewed during the Payroll month-end cycle. Planned date of completion: bi-monthly payroll closes on the 10th and 25th of each month, respectively.
Finding 520000 (2024-001)
Significant Deficiency 2024
12/11/2024 LifeLong Medical Care Corrective Action Plan For the year ended June 30, 2024 2024-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Brent Copen, CFO Corrective Action: LifeLong Medical Care will: - Immediately retrain s...
12/11/2024 LifeLong Medical Care Corrective Action Plan For the year ended June 30, 2024 2024-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Brent Copen, CFO Corrective Action: LifeLong Medical Care will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions. Proposed Completion Date: June 30, 2025
Action to be Taken: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future. This issue was isolated to a specific payroll, where a report did not function as intended. No issues were detected with either prior or future payrolls. However,...
Action to be Taken: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future. This issue was isolated to a specific payroll, where a report did not function as intended. No issues were detected with either prior or future payrolls. However, we have implemented the additional step of checking these reports to timesheets to ensure there are no discrepancies.
View Audit 339414 Questioned Costs: $1
Finding 519870 (2024-003)
Significant Deficiency 2024
Name of Contact Person: Jennifer Herman, Finance Director Corrective Action: 1. The Finance Office will no longer make corrections on employee mileage and meal reimbursement forms submitted by County departments. Finance Office staff will return incorrect forms for departmental personnel to make...
Name of Contact Person: Jennifer Herman, Finance Director Corrective Action: 1. The Finance Office will no longer make corrections on employee mileage and meal reimbursement forms submitted by County departments. Finance Office staff will return incorrect forms for departmental personnel to make corrections and resubmit the reimbursement form. Proposed Completion Date: This plan has been implemented since October 1, 2024. 2. The County will update its travel policy and require County department heads to be responsible for the use of approved rates on employee travel reimbursement forms. Proposed Completion Date: January 1, 2025.
View Audit 339174 Questioned Costs: $1
Finding 519866 (2024-002)
Significant Deficiency 2024
Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. Alexander County DSS has implemented more detailed Indirect Cost Plan review to ensure that the County Manager signed plan is utilized and not the Final (Draft) version. The Business Officer will further train in t...
Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. Alexander County DSS has implemented more detailed Indirect Cost Plan review to ensure that the County Manager signed plan is utilized and not the Final (Draft) version. The Business Officer will further train in the differences between the two documents to ensure the proper one is reviewed and financial data is transferred over to the 1571 mthly cost statements. Proposed Completion Date: Reviewing of the two versions of the Indirect Cost Plans by the DSS Business Officer has been completed as of August 6th, 2024 once the Signed FY23 Indirect Cost plan was obtained. DSS Business Officer will continue a review process every fiscal year once the newly signed plan is received. 2. The DSS Director and Business Office team will review the Official Indirect Cost Plans annually and check the 1571 Statement of Admin. letters mthly to ensure accuracy in the Indirect Cost Plan financial data. Proposed Completion Date: August 6th, 2024
View Audit 339174 Questioned Costs: $1
Finding 519862 (2024-001)
Significant Deficiency 2024
Corrective Action Plan for Finding 2024-001 Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. On May 7th and May 17th, job counseling sessions and written warnings were given to the employees who were flagged for not logging out or locking their screens to protect...
Corrective Action Plan for Finding 2024-001 Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. On May 7th and May 17th, job counseling sessions and written warnings were given to the employees who were flagged for not logging out or locking their screens to protect confidential information. In addition, On July 2nd, a staff meeting was completed to review agency policy on PII requirements and expectations and I.T. has changed lock out screen settings to take place after 3 minutes of inactivity on all DSS Computer Systems. Proposed Completion Date: PII Policy Enforcement, Training Reviews, Security Implementations have been completed as of 7/2/24. 2. The DSS Director and Agency Admin. team will randomly check office computers to ensure systems are locked per policy. Proposed Completion Date: July 2, 2024
Information on the Federal Program: U.S. Department of Education, Trio Cluster and Appalachian Regional Commission (ARC), Appalachian Area Development Assistance Listing No. 23.002 Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfeder...
Information on the Federal Program: U.S. Department of Education, Trio Cluster and Appalachian Regional Commission (ARC), Appalachian Area Development Assistance Listing No. 23.002 Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfederal entities are also required to establish controls over the disbursement process to ensure compliance with allowable cost requirements. Condition: We selected a Trio sample of 25 payroll charges, containing 56 employee paychecks. Of those 56, five employee's approved pay was not properly documented. The employee had additional pay not on the approved Letter of Appointment (LOA) or the LOA reflected the use of restricted dollars, but the pay was charged to the grant. In addition, of those 56, five employees were charged to a grant that they were not budgeted for. We selected an ARC sample of 10 nonpayroll disbursements to test for controls. Of those 10, one disbursement of four scholarships was not properly documented as approved for payment. Management’s Response: The College will strengthen its policies and procedures surrounding the disbursement process. The College will document approvals on all payroll changes at the college and on the grant budgets. All scholarships will have prior written approval before scholarships will be applied. The College will also amend all grants when needed to properly reflect all job titles and expenditure items. Anticipated Completion Date: February 28, 2025
View Audit 339006 Questioned Costs: $1
2024-001 - Housing Voucher Cluster - Assistance Listing No. 14.871 Recommendation: The Authority should review their HQS inspection policies to ensure that all inspections are performed timely, and that all necessary documentation is maintained for each inspection. Explanation of disagreement with ...
2024-001 - Housing Voucher Cluster - Assistance Listing No. 14.871 Recommendation: The Authority should review their HQS inspection policies to ensure that all inspections are performed timely, and that all necessary documentation is maintained for each inspection. Explanation of disagreement with audit finding: There is no disagreement with the audit finding; however as explained to the auditor, the one unit noted by the audit was an action from 2021 or prior, and the auditor was provided results from current 2023/2024 inspection. Action taken in response to finding: The Northwest Oregon Housing Authority has reviewed its inspection policies regarding timely inspections. All units are being scheduled in a biennial cycle in 2023 and 2024, and beyond, thus resolving this finding. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 12/31/2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Hsu-Feng Andy Shaw, Executive Director, at 503-861-0119.
Management's Response: Management concurs with the above finding and all documentation for annual reports will be held and kept as required moving forward. This will be implemented with the 2025 annual report.
Management's Response: Management concurs with the above finding and all documentation for annual reports will be held and kept as required moving forward. This will be implemented with the 2025 annual report.
Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC spe...
Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC specialist helped the college set up an additional "subsequent of term" submission roughly 30 days after the end of the semester but prior to the first upload of the following semester. As a nonattendance taking institution, this timeframe will allow the college a chance to make withdrawal determinations for students who did not officially withdraw but stopped attending at some point in the semester and code them appropriately in Banner. This action has occurred, been tested and implemented as of January 2025.
2024-004 Contact Person David Klein, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP June 30, 2025
2024-004 Contact Person David Klein, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP June 30, 2025
Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to th...
Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to the adverse opinion on the 2022 financial statements and related disclaimer of opinion included in our accompanying 2023 Independent Auditor's Report Response: The hospital has financial covenants including: Maintaining 35 days cash on hand. We are currently at 26 Days Cash on Hand. The hospital has been as low as 6 Days Cash on Hand. To increase our Cash on Hand, we have brought all Revenue Cycle efforts in house, trained new staff, formed cross functional teams with the clinical documentation staff, set goals and work weekly with our teams to gently resolve challenges and move forward. These efforts have rewarded the hospital with increased Days Cash on Hand and improved quality processes in Revenue Cycle. One covenant requires that we maintain strong internal controls. Since the new administration have begun, each month, new internal controls are being established throughout the hospital, Finance department, Materials Management and the Revenue Cycle. On covenant requires a positive bottom line. The hospital has been losing money primarily due to the change in administration, lack of routine processes, recruitment challenges, lack of accuracy in our accounting and revenue cycle. Throughout the hospital and RHC’s, improvement teams are working to both improve quality processes, reduce costs, establish a culture to allow recruitment and improve our bottom line. The hospital has been transparent with the agency and our Board of Directors throughout our change process. More work continues. Responsible Party: Meagan Weber, CEO, Brent Peirick, COO, Carolyn Davies, CFO Estimated Completion Date: 12/31/2026
Condition: The District did not meet its financial reporting obligations under the grant during the year. The District did not complete the 2022 audit and file the Data Collection Form (SFSAC) by the due date of March 31, 2024 Response: The financial statement audit for FY 2022 is complete and we ar...
Condition: The District did not meet its financial reporting obligations under the grant during the year. The District did not complete the 2022 audit and file the Data Collection Form (SFSAC) by the due date of March 31, 2024 Response: The financial statement audit for FY 2022 is complete and we are awaiting issuance of the single audit for FY 2022. We anticipate the single audit stand-alone report will be issued prior to the end of 2025. The 2022 Report on Internal Control Over Financial Reporting and On Compliance and Other Matters Based on an Audit of Financial Statements Performed In Accordance with Government Auditing Standards has not been issued. We are currently working with our grantors and lenders to determine the appropriate course of action for not having this report. The hospital’s plan is to maintain timely completion of the financial audits in future years. Responsible Party: Meagan Weber, CEO, Brent Peirick, COO, Carolyn Davies, CFO Estimated Completion Date: 12/31/2025
Planned Corrective Action: I acknowledge the identified instance where supervisory approval was not obtained for a documented personnel expense. We have taken immediate steps to address this issue by implementing a more robust process to ensure that all personnel expense documentation is reviewed an...
Planned Corrective Action: I acknowledge the identified instance where supervisory approval was not obtained for a documented personnel expense. We have taken immediate steps to address this issue by implementing a more robust process to ensure that all personnel expense documentation is reviewed and approved by a supervisory-level employee before submission. Additionally, we will reinforce this practice through staff training and remind supervisors of their responsibility to approve all personnel expense reports. We are committed to maintaining strong internal controls, and we will monitor the implementation of this process to ensure compliance and reduce the risk of unallowable costs in the future. Anticipated Completion Date: Immediately Responsible Contact Person: Danielle Devoll
Finding Number: 2024-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2025 Responsible Contact Person: Dave Massa, Treasurer
Finding Number: 2024-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2025 Responsible Contact Person: Dave Massa, Treasurer
Airport Improvement Program – 20.106 Recommendation: Procedures should be put in place to ensure the data collection form is submitted to the FAC timely. Action Taken: Airport management will ensure the data collection form is submitted to the FAC timely.
Airport Improvement Program – 20.106 Recommendation: Procedures should be put in place to ensure the data collection form is submitted to the FAC timely. Action Taken: Airport management will ensure the data collection form is submitted to the FAC timely.
Finding 519712 (2024-003)
Significant Deficiency 2024
Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: Southwestern now has an internal review in place to ensure that all calculations are done within the time allotment for the R2T4. We are also working very closely with the Registrar’s Office to ensure that all withdrawals are su...
Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: Southwestern now has an internal review in place to ensure that all calculations are done within the time allotment for the R2T4. We are also working very closely with the Registrar’s Office to ensure that all withdrawals are submitted to our office timely. Person Responsible for Corrective Action Plan: Brenda Hicks, Associate Vice President of Student Financial Planning and Director of Financial Aid Anticipated Date of Completion: Ongoing, process began in October, 2024.
Third Party Servicer Reporting Recommendation: We recommend the College review its reporting procedures surrounding their third party servicer to ensure reporting is accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken i...
Third Party Servicer Reporting Recommendation: We recommend the College review its reporting procedures surrounding their third party servicer to ensure reporting is accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Based upon previous year finding, the College updated the third party servicer in one federal system and on the College’s website. There was a second system that was not updated. The third party servicer will be updated in the second system immediately. Name(s) of the contact person(s) responsible for corrective action: Michele Peterson Planned completion date for corrective action plan: 12/31/2024
National Student Loan Database System (NSLDS) Enrollment Reporting Recommendation: We recommend the College reevaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure timely and accurate reporting. Explanation of disagreement with audit finding: There is ...
National Student Loan Database System (NSLDS) Enrollment Reporting Recommendation: We recommend the College reevaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure timely and accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar will re-evaluate policies, procedures and training materials to ensure timely and accurate reporting. Name(s) of the contact person(s) responsible for corrective action: Michele Peterson Planned completion date for corrective action plan: 03/31/2024
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to fed...
Finding Number: 2024-004 Condition: The College does not have a written cash management policy related to federal awards. Planned Corrective Action: In accordance with 2 CFR 200.302(b)(6), the College will establish a written cash management policy, including written procedures related to federal payments/awards in order to implement the requirements of 200.305. Contact person responsible for corrective action: David Cummins, Vice President for Administrative Services and College Treasurer Anticipated Completion Date: As soon as possible moving forward starting December 18, 2024.
Processes will be implemented to review, update and verify data captured by NSLDS and ensure such data has been accurately reported in a timely manner.
Processes will be implemented to review, update and verify data captured by NSLDS and ensure such data has been accurately reported in a timely manner.
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. ...
We have implemented the following protocol to ensure the accuracy of the Form 801A State Attendance Reporting: The site supervisor prepares a Monthly Attendance Form from the daily Attendance Sign-in Sheets and submits it to the ECE Director of Programs, with a copy to the Enrollment Coordinator. The Enrollment Coordinator reviews the accuracy of the report based on a re-comparison to source sign-in/sign-out sheets, as well as other source information, and submits the report, corrected as necessary, to the ECE Director of Programs. The ECE Director of Programs will review and approve to submit for reporting and invoicing. Once approved, the monthly forms are submitted to the finance department by the site supervisor. GFS’s finance team will complete one more review of the totals before submitting to the CDE and CDSS.
Management concurs with the finding. Beginning in fiscal 2025, management will open an interest bearing account insured by the Federal Deposit Insurance Corporation (“FDIC”) and transfer funds to the account to comply with HUD requirements. Our policies and procedures manual will be updated to mor...
Management concurs with the finding. Beginning in fiscal 2025, management will open an interest bearing account insured by the Federal Deposit Insurance Corporation (“FDIC”) and transfer funds to the account to comply with HUD requirements. Our policies and procedures manual will be updated to more clearly specify this HUD compliance requirement. We will continuously monitor HUD’s overall requirements, in order to maintain compliance on an ongoing basis.
Finding 519612 (2024-002)
Significant Deficiency 2024
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A new Registrar was hired in late May of 2024. A new process was implemented for the Fall semester of 2024 to ensure timely and accurate processing of official and unofficial withdrawals. Outcom...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A new Registrar was hired in late May of 2024. A new process was implemented for the Fall semester of 2024 to ensure timely and accurate processing of official and unofficial withdrawals. Outcome: All student withdrawal requests both official and unofficial are processed daily and tracked in a shared workbook. This allows information about each individual withdrawal request to be captured and available for both the Business Office and Financial Aid. Date of Determination, Last Date of Attendance, Processed Date, withdrawal type, withdrawal reason, and credits impacted are all captured in the workbook to aid with R2T4 calculations. This workbook also serves as a document that can be audited in real-time to ensure accuracy of each student’s record. A Standard Operating Procedure was developed and used to train the team members effective on 8/12/2024. Person Responsible for Corrective Action Plan: Tonya Troka, University Registrar & Assistant Provost Anticipated Date of Completion: Completed and implemented for Fall 2024 Semester
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