Corrective Action Plans

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The District will thoroughly examine all grant disclosures and requirements, follow guidance provided, and maintain records related to all reporting. Treasurer has communicated that all district expenditure data reporting be completed by Treasurer/CFO in the future.
The District will thoroughly examine all grant disclosures and requirements, follow guidance provided, and maintain records related to all reporting. Treasurer has communicated that all district expenditure data reporting be completed by Treasurer/CFO in the future.
FINDING 2024-002 Finding Subject: Drinking Water State Revolving Fund - Procurement and Suspension and Debarment Summary of Finding: Controls were not in place to ensure the Town followed its procedures for suspension and debarment. Contact Person Responsible for Corrective Action: Aaron Kaytar Cont...
FINDING 2024-002 Finding Subject: Drinking Water State Revolving Fund - Procurement and Suspension and Debarment Summary of Finding: Controls were not in place to ensure the Town followed its procedures for suspension and debarment. Contact Person Responsible for Corrective Action: Aaron Kaytar Contact Phone Number and Email Address: 317-852-1120 akaytar@brownsburg.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: In 2023 a Purchasing Policy was implemented for all departments to follow. It states: To provide services to the Town of Brownsburg, you must not be debarred, suspended, or otherwise be excluded from or ineligible for participation in federally assisted programs under Executive Order 12549. Upon entering contracts, the Capital Projects and Procurement manager will ensure a vendor is not suspended or debarred by following one of the three acceptable means as required by the federal government. All contracts are reviewed and approved by the Town Council. Anticipated Completion Date: January 1, 2025
FINDING 2024-001 Finding Subject: SLFRF - Procurement, Suspension and Debarment Summary of Finding: Controls were not in place to ensure the Town followed its procedures for suspension and debarment. Contact Person Responsible for Corrective Action: Aaron Kaytar Contact Phone Number and Email Addres...
FINDING 2024-001 Finding Subject: SLFRF - Procurement, Suspension and Debarment Summary of Finding: Controls were not in place to ensure the Town followed its procedures for suspension and debarment. Contact Person Responsible for Corrective Action: Aaron Kaytar Contact Phone Number and Email Address: 317-852-1120 akaytar@brownsburg.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: In 2023 a Purchasing Policy was implemented for all departments to follow. It states: To provide services to the Town of Brownsburg, you must not be debarred, suspended, or otherwise be excluded from or ineligible for participation in federally assisted programs under Executive Order 12549. Upon entering contracts, the Capital Projects and Procurement manager will ensure a vendor is not suspended or debarred by following one of the three acceptable means as required by the federal government. All contracts are reviewed and approved by the Town Council. Anticipated Completion Date: January 1, 2025
CORRECTIVE ACTION PLAN May 15, 2024 Agency: U.S. Department of Health and Human Services: Health Resources and Services Administration (HRSA) Paterson Community Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. ___________________________...
CORRECTIVE ACTION PLAN May 15, 2024 Agency: U.S. Department of Health and Human Services: Health Resources and Services Administration (HRSA) Paterson Community Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. ______________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: 12/31/2024 The findings from the 12/31/2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule.Section III - Federal and State Awards Findings and Questioned Costs Significant Deficiency I Item 2024-001 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000163, H8F41100 for 2024 Recommendation: We recommend that the Center train its personnel in relation to the exclusion screening and proper documentation thereof and that the Center conduct regular reviews to ensure the completeness of exclusion search documentation. Action taken: We will ensure that the center's personnel are trained in the exclusion screening, maintain the location of the proper documentation, and conduct regular reviews to ensure the completeness of exclusion search documentation. The center performs background checks but was unable to locate the documents for those two new employees who were terminated but will ensure that we will put control processes in place to make sure we can demonstrate that the exclusion search was conducted. If the Health Resources and Services Administration has questions regarding this plan, please call Debora Walcott, Chief Financial Officer at 973-790-6594 ext. 320. Sincerely yours,
Planned Corrective Action: The 603LA Accounting Manual has been updated and completed, taking into consideration the requirements of the 2023 LSC Financial Guide, including the completion of the Self-Assessment Questionnaire (Appendix 9) of the Guide. The Board of Directors reviewed, approved, and ...
Planned Corrective Action: The 603LA Accounting Manual has been updated and completed, taking into consideration the requirements of the 2023 LSC Financial Guide, including the completion of the Self-Assessment Questionnaire (Appendix 9) of the Guide. The Board of Directors reviewed, approved, and codified the Accounting Manual at the May 28, 2025 Board of Directors meeting. Responsible Person: Controller. Date of Completion: Compliant as of May 2025.
Corrective Action Plan: Finding 2024‐001 Responsible: Roseann Hayes, Emily Lewis, George Moore DD Recommendation: We recommend the Organization establish procedures for the preparation, review and timely submission of all reporting requirements. This can include implementing a system to track report...
Corrective Action Plan: Finding 2024‐001 Responsible: Roseann Hayes, Emily Lewis, George Moore DD Recommendation: We recommend the Organization establish procedures for the preparation, review and timely submission of all reporting requirements. This can include implementing a system to track reporting deadlines and timely submission as well as designating individuals with the responsibilities of preparation, review, and submission of reports. Additionally, we recommend the Organization designate someone to review the grant documents for all compliance requirements to ensure nothing is missed. Corrective Action Summary: • Advancement and Finance will create an updated Grants Management process • This Grants Management process will: o Be documented o Clearly define roles for Advancement and Finance staff o Create a flowchart to define what type of grant has been awarded (conditional vs. unconditional) o Assure awarded grants are reviewed for all performance, outcomes, invoicing and reporting requirements o Define who sets up calendar reminders for grant milestones (i.e. reporting) o Define how Program staff will be selected to receive these calendar reminders Anticipated Completion Date: 6/30/2025
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: ...
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021), S425U210012 (Year: 2021) Questioned Costs: $72,595 Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund programs revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were properly recorded. Corrective Action Plans: Our office was unaware our financial program could automatically generate employee's supplemental checks in addition to standard monthly checks. Now that we are aware, Ivey McLendon and I will monitor our financial program's automatically generated claims closely to adapt our manual accrual entries. Estimated Completion Date: June 30, 2025 Contact Person: Sherry Gray, Financial Director Telephone: (229) 524-2433 Email: sgray@seminole.k12.ga.us
View Audit 358065 Questioned Costs: $1
Recommendation: We recommend the organization revisit its policies and procedures surrounding management’s review of grant and other contractual agreements to ensure all federal assistance, including subawards, are properly identified as such at the time the agreements are signed or received, and ar...
Recommendation: We recommend the organization revisit its policies and procedures surrounding management’s review of grant and other contractual agreements to ensure all federal assistance, including subawards, are properly identified as such at the time the agreements are signed or received, and are properly included on the SEFA. ODI agrees with the auditors’ recommendation. Consistent with response to finding 2024-001, we have reviewed the design and implementation of internal controls procedures around accounting for grants and contracts. This has resulted in revision of our new funding form including identifying federal and nonfederal designations in subcontracts from states, and determination of conditions to ensure compliance with U.S. GAAP. Responsible staff member, Laurie Larson-Lewis, Finance Manager, completion date 5/31/2025.
Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-005 - Procu...
Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-005 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00646-22-03, 2 H80CS005646-23-00, 4 H8GCS48213-01-01, 1 H8LCS51923-01-00 for 2023 and 2024 - (Significant Deficiency) During our audit, we noted that certain employees have no record of an exclusion search conducted during 2024. There were also certain employees for whom an exclusion search was not consistently conducted on a monthly basis. Recommendation We recommend that the Center train its personnel in relation to the exclusion screening and proper documentation thereof and that the Center conduct regular reviews to ensure the completeness of exclusion search documentation. Action Taken Management agrees with the finding and will be conducting training for its personnel to help ensure the accuracy, completeness and timeliness of exclusion searches. Effectivity Date: June 30, 2025
Finding 563807 (2024-001)
Significant Deficiency 2024
Finding 2024-001: Cash Management Federal Grant – ALN 93.788 and ALN 93.959 Condition – During testing, it was noted that cash was requested prior to disbursement of funds by a month or more. Corrective Action –HealthWest finance management will conduct a mandatory staff training session for all r...
Finding 2024-001: Cash Management Federal Grant – ALN 93.788 and ALN 93.959 Condition – During testing, it was noted that cash was requested prior to disbursement of funds by a month or more. Corrective Action –HealthWest finance management will conduct a mandatory staff training session for all relevant staff on cash management requirements, including timing of cash requests, documentation of expenditures, and consequences of non-compliance. Refresher grant compliance and cash management policy review and training will be incorporated into annual training for all grant management personnel. HealthWest will update grant pre-draw process to require a documented review and approval of all cash draw requests by finance leadership or designee ensuring drawdowns are supported by general ledger expenditure activity reports. Contract Person – Brandy Carlson, Chief Financial Officer Anticipated Completion Date – June 30, 2025
Finding Reference Number: 2024-004 Reporting Description of Finding: During the fiscal year ended June 30, 2024, the Authority's internal controls over the submission of VMS to HUD did not include a review or reconciliation of the information submitted to supporting documentation. As a result, hous...
Finding Reference Number: 2024-004 Reporting Description of Finding: During the fiscal year ended June 30, 2024, the Authority's internal controls over the submission of VMS to HUD did not include a review or reconciliation of the information submitted to supporting documentation. As a result, housing assistance payments for Mainstream Port-out vouchers were not reported in VMS. Statement of Concurrence or Nonconcurrence: The Wallingford Housing Authority agrees and accepts the above reference findings. Corrective Action Plan: Maintaining a properly staffed and trained staff will ensure that each montky VMS report will be reconciled prior to being submitted by the third-party fee accountant. A schedule or reconciliations will be created and implemented.
Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-002 – Eligibility - Pell Finding: Herzing University did not properly award Pell funding to an eligible student in the Spring 2024 semeste...
Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-002 – Eligibility - Pell Finding: Herzing University did not properly award Pell funding to an eligible student in the Spring 2024 semester. Condition: A student was eligible to receive Pell funding but did not receive Pell funds due to an employee error. For one out of 40 students tested for eligibility, we noted 1 student (2.5%) who was eligible to receive Pell funding but did not receive Pell funds due to an employee error. Action Taken: The identified student withdrew from the University on May 8, 2023. The student’s 2023-24 Pell award was cancelled during the required R2T4 process that was completed on May 23, 2023. The 2023-24 Pell award for the Spring 2024 semester was not manually reinstated upon the student’s return to an Active status on June 28, 2023. The employee who was responsible for updating the student’s financial aid package upon the student’s return to an Active status erroneously neglected to reinstate the 2023-24 Pell award for the Spring 2024 semester. This finding is attributed to human error. In April 2025, Herzing University created an internal compliance checkpoint for Pell awarding. This checkpoint will identify any students with a Pell eligible SAI for the Federal Award year that do not have Pell packaged for the semester. This checkpoint was completed for the Spring 2025 semester on April 7, 2025, and will be completed each semester going forward. Any affected students identified during the completion of this semester-based checkpoint will have their financial aid package revised to include Pell funding for the applicable semester, prior to the end of the semester. Herzing University’s Policy Manual was updated in April 2025 to reflect the addition of the Pell Awarding compliance checkpoint. For the identified student, Herzing University has provided a tuition waiver for the amount of the Pell funds that the student was eligible for and should have received for the Spring 2024 semester. The required corrective action for Finding 2024-002 listed in the SFA audit for the period 1/1/2024 – 12/31/2024 was completed on 5/7/2025. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance. ____________________________________ _______________________ Kevin McShane Date Vice President of Financial Aid & Compliance Herzing University 275 W. Wisconsin Ave., Ste. 210, Milwaukee, WI 53203 Email Address: kmcshane@herzing.edu
Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-001 – Eligibility - SEOG Finding: Herzing University did not properly award SEOG funding to an eligible student in the Fall 2024 semester....
Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-001 – Eligibility - SEOG Finding: Herzing University did not properly award SEOG funding to an eligible student in the Fall 2024 semester. Condition: A student was eligible to receive SEOG funding but did not receive SEOG funds due to an employee error. For one out of 40 students tested for eligibility, we noted 1 student (2.5%) who was eligible to receive SEOG funding but did not receive SEOG funds due to an employee error. Action Taken: On May 1, 2024, a Financial Aid Advisor manually cancelled the identified student’s 2024-25 SEOG award in Regent (Herzing University’s Financial Aid Management Software), with a notation that the student had an ineligible Student Aid Index (SAI). The student had an SAI of -117 on their 2024-25 ISIR, and in accordance with Herzing University’s FSEOG policy were eligible for 2024-25 SEOG in the Fall 2024 semester. The award was incorrectly manually canceled by the advisor because of human error. In April 2025, Herzing University created an internal compliance checkpoint for FSEOG awarding. This checkpoint will serve as a safety net to identify any students who have a Pell award for the Federal Award year, have an SAI that is FSEOG eligible according to Herzing University’s FSEOG policy, and do not correctly have FSEOG packaged for the semester. Any affected students identified during the completion of this semester-based checkpoint will have their financial aid package reviewed and if necessary revised to include FSEOG funding for the applicable semester, prior to the end of the semester. This checkpoint was completed for the Spring 2025 semester on April 4, 2025, and will be completed each semester going forward. Herzing University’s Policy Manual was updated in April 2025 to reflect the addition of the FSEOG Awarding compliance checkpoint. For the identified student, Herzing University has provided a tuition waiver for the amount of the FSEOG funds that the student was eligible for and should have received for the Fall 2024 semester. The required corrective action for Finding 2024-001 listed in the SFA audit for the period 1/1/2024 – 12/31/2024 was completed on 5/7/2025. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance. ____________________________________ _______________________ Kevin McShane Date Vice President of Financial Aid & Compliance Herzing University 275 W. Wisconsin Ave., Ste. 210, Milwaukee, WI 53203 Email Address: kmcshane@herzing.edu
Finding 563693 (2024-002)
Material Weakness 2024
Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.
Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Variou...
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Various agencies Award Names: Enabling Low Temperature Plasma (LTP) Ignition Technologies for Multi- Mode Engines Through the Development of a Validated High Fidelity LTP Model for Predictive Simulation Tools, Greater Alabama Black Belt Region (GABBR) LSAMP, and Reimagining controlled environment agriculture in a low carbon world Award Numbers: 211809, 200634, and 205280 Assistance Listing Title: Conservation Research and Development, STEM Education (formerly Education and Human Resources), Agriculture and Food Research Initiative (AFRI) Assistance Listing Number: 81.086, 47.076, and 10.310 Award Year: 2023 - 2024 Pass-through entity: University of Texas Dallas, Association of Public & Land Grant Universities, Tuskegee University, and Clemson University To ensure Auburn University is in compliance with 2CFR 200.332(f), Auburn University has implemented the following corrective action plan: Since the audit period, the University has started a comprehensive review of its subrecipient monitoring framework and has been working to distribute workload more effectively with the goal of building consistency in subrecipient monitoring procedures. This includes efforts to clarify ownership of monitoring tasks, implementing a more centralized and standardized approach to documentation, and balancing the day-to-day operational duties across the subaward team to allow for appropriate focus on Uniform Guidance compliance. Brief internal training sessions or check-ins will be conducted to reinforce expectations and ensure that all staff are aligned with the updated documentation practices. Current procedures will be revised to address risk assessments and annual monitoring. These improvements are designed to ensure consistency, accountability, and compliance with Uniform Guidance expectations moving forward. We will document when all reviews of sub-recipients’ financial statements/Uniform Guidance reports occur and who completed the reviews. These reviews will be entity-specific and conducted annually. The corrective actions noted herein are in process and implementation is expected before the end of the current fiscal year to allow adequate time for review, development, and benchmarking. Contact: Tony Ventimiglia Asst. VP Research Administration Office of the Senior VP for Research & Economic Development Amy Douglas Associate VP Financial Services/Controller Anticipated Completion Date: October 1, 2025
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, SNAP, and also applies to COVID-19 – Coronavirus State and Local Fisca...
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, SNAP, and also applies to COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, which is not a cluster Sponsoring Agency: Various agencies Award Names: DE-CR0000033, USDA-58-6010-9-011, WICHITA ST UN-23-01534, AL DHR-AGREE 4153-FY24, and ADF-RURAL HLTH INITIATIVE-OPS Award Numbers: 212514, 204805, 245195, 376563, and 223331 Assistance Listing Title: Cybersecurity, Energy Security & Emergency Response (CESER), Agricultural Research Basic and Applied Research, Other Financial Assistance, State Administrative Matching Grants for the Supplemental Nutrition Assistance Program, and COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 81.008, 10.001, 12.RD, 10.561, and 21.027 Award Year: 2023 – 2024 To ensure Auburn University is in compliance with 2CFR 200.324, Auburn University will implement the following corrective action plan: In addition to our current policies that require three quotes for purchases between $15,000-$75,000 and a formal competitive bid for purchases greater than $75,000, Auburn University will revise our policies to require a cost or price analysis for items greater than $250,000, documenting that the purchase is reasonable. The items identified within the audit were either a Professional Service Contract, advertising services (which are both exempt from State of Alabama Bid Law) or a sole source purchase. For items greater than $250,000, we will include a certification on the Professional Services Contracts and the Sole Source request forms indicating an analysis of cost or price has occurred and that the purchase is reasonable. As part of the cost or price analysis, we will utilize available data points. In addition to our analysis, we will ensure that our reviews have been appropriately documented and included in our files. Prior to the implementation date noted below, we will review any purchases greater than $250,000 in fiscal year 2025 and ensure proper cost or price analysis is completed and documented. Contact: Missty Kennedy Chief Procurement Officer and Executive Director Procurement and Payment Services Amy Douglas Associate VP Financial Services/Controller Anticipated Completion Date: October 1, 2025
Finding 563656 (2024-001)
Significant Deficiency 2024
Segregation of Duties
Segregation of Duties
Finding 563656 (2024-001)
Significant Deficiency 2024
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties...
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties or add mitigating controls to prevent material misstatement of the financial statements.
Finding 563656 (2024-001)
Significant Deficiency 2024
Management’s Response and Actions Planned: The City’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following:
Management’s Response and Actions Planned: The City’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following:
Finding 563656 (2024-001)
Significant Deficiency 2024
1.      Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring.
1.      Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring.
Finding 563656 (2024-001)
Significant Deficiency 2024
2.      Implements limited segregation to the extent possible to reduce risks without impairing efficiency.
2.      Implements limited segregation to the extent possible to reduce risks without impairing efficiency.
Finding 563656 (2024-001)
Significant Deficiency 2024
3.      Uses the knowledge that management and the Board of Directors have of operations by having them review certain accounting records and reports.
3.      Uses the knowledge that management and the Board of Directors have of operations by having them review certain accounting records and reports.
Finding 563656 (2024-001)
Significant Deficiency 2024
Monitors the effectiveness of the above actions and makes changes as considered appropriate.
Monitors the effectiveness of the above actions and makes changes as considered appropriate.
2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of H...
2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 29 CUA Safety Assessments, (b) 30 CUA Safety Plans, (c) 7 CUA PA Model Risk Assessments, (d) 3 CUA Documented Client Visits (Structure Case Notes), (e) FAST Family Advocacy Forms, (f) 17 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 11 School Aged Report Cards, (h) 6 CUA Authorization to Release Information, (i) 9 CUA Immunizations, (j) 3 DHS Court Order Sheets, (k) 14 Child’s Photo, (l) 10 Initial CUA Single Case Plan, (m) 7 Monthly Updates to CUA Single Case Plan, (n) 17 Initial CUA Case Service Conference Summary Report, and (o) 16 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 34 DHS Service Authorization Forms, (b) 21 DHS CUA Provider Referral Forms, and (c) 30 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. FINDINGS – FEDERAL AWARD PROGRAM AUDITS (CONTINUED) Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Staffing of Quality Assurance department 3. Monthly review of client files for accuracy and completeness 4. Additional training of staff to review audit findings and implement corrective action Name of the contact person responsible for corrective action: Albert Essilfie, Chief Financial Officer albert.essilfie@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2025
Finding 563583 (2024-002)
Significant Deficiency 2024
We agree with the finding and have already implemented corrective actions to ensure it does not occur again. Additionally, this procedure has been added to our compliance checklist, which is reviewed on a monthly basis to ensure adherence.
We agree with the finding and have already implemented corrective actions to ensure it does not occur again. Additionally, this procedure has been added to our compliance checklist, which is reviewed on a monthly basis to ensure adherence.
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