Corrective Action Plans

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Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY22; INORPS61 1-FY23; INORWB611-GY23 Awards: Assistance Listing Number 93.917 - HIV Emergency Relief Project Grants...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY22; INORPS61 1-FY23; INORWB611-GY23 Awards: Assistance Listing Number 93.917 - HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2022 to March 31, 2023; July 1, 2022 to March 31, 2023; April 1, 2023 to March 31, 2024 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: Management should formally discharge any clients that are unable to complete the eligibility screening prior to the end of the 24-month eligibility period. View of responsible officials: Management concurs with the finding and will implement procedures to ensure that timely documentation is received with regard to eligibility. Name(s) of the Contact Person(s) Responsible for Corrective Action: Mara Carter, Senior Director Community Health, 703-321-2687. Corrective Action Planned: Inova will continue to adhere to the 24-month eligibility set forth by VDH, and not provide any services to RWHAP clients who have not completed their reassessment within the required 24-month period. Inova will update its reminder system to contact clients who are nearing the end of their eligibility period to make sure that they do not have a break in service, VDH suggests 30-45 days prior to their 24-month eligibility date. Inova will institute its own monthly tracking outside of Provide to more effectively track clients and their 24-month eligibility. RWHAP clients who fail to provide reassessment documentation will be terminated from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2024.
Management agrees with this finding. The presentation of the CDBG-DR fund was caused by the significant time and effort that requires the accounting of the new fund and the understaffing of the accounting department. Management is making arrangements to modify accounting system and procedures to asc...
Management agrees with this finding. The presentation of the CDBG-DR fund was caused by the significant time and effort that requires the accounting of the new fund and the understaffing of the accounting department. Management is making arrangements to modify accounting system and procedures to ascertain all transactions related to the CDBG-DR Fund are presented in the Bank's general ledger on a monthly basis. Also, the Bank is working toward recruiting additional personnel for the accounting department.
Management agrees with the finding. The amendment in the Subrecipient Agreement to increase the grant awards from $50,000 to $150,000 resulted in new information provided by customers replacing in the Award Management Application’s, (Canopy), old information used in the original grant award. The ban...
Management agrees with the finding. The amendment in the Subrecipient Agreement to increase the grant awards from $50,000 to $150,000 resulted in new information provided by customers replacing in the Award Management Application’s, (Canopy), old information used in the original grant award. The bank established new procedures/requirements to avoid duplicate disbursements and/or confirm customers' bank accounts before processing transactions. All resources working on the CDBG-DR Small Business Financing (SBF) project have been trained to perform their role in accordance with the Program Guidelines, SOPs, and regulations. Cases identified with deficiencies, as part of the 2023 Single Audit at the Grant Awarding and Closing Stages, will be used as examples to prevent this situation from repeating in the future and to establish additional quality control (QC) by Team Leaders. Additionally, recapture (repayment by the Grantee of any Grant amount received) of awarded and disbursed funds will apply when there's failure to comply with the SBF Program Guidelines.
Management agrees with this finding. All resources that work the CDBG-DR Small Business Financing (SBF) project have been trained to perform their role according to the Program Guidelines, SOP's and regulations. The cases identified with deficiencies, as part of the Single Audit 2023 in the Intake, ...
Management agrees with this finding. All resources that work the CDBG-DR Small Business Financing (SBF) project have been trained to perform their role according to the Program Guidelines, SOP's and regulations. The cases identified with deficiencies, as part of the Single Audit 2023 in the Intake, Underwriting and Expenditure Review & Closeout stages will be used as examples to prevent this situation from occurring in future cases and establish additional Team Lead quality control (QC). Additionally, recapture (repayment by the Grantee of any Grant amount received) of awarded and disbursed funds will apply when there's failure to comply with the SBF Program Guidelines.
Finding 504476 (2023-003)
Significant Deficiency 2023
Management understands the importance of implementing a risk assessment process. This observation has been noted for future compliance.
Management understands the importance of implementing a risk assessment process. This observation has been noted for future compliance.
Finding 2023-002 - Department of Health and Human Services – Research & Development Cluster- Subrecipient Monitoring Statement of Condition: No formal documentation existed to indicate that the Foundation performed the required monitoring of its subrecipient’s activity and no written policy exists ...
Finding 2023-002 - Department of Health and Human Services – Research & Development Cluster- Subrecipient Monitoring Statement of Condition: No formal documentation existed to indicate that the Foundation performed the required monitoring of its subrecipient’s activity and no written policy exists to establish procedures to document the monitoring of the subrecipient. Management Response: The RTOG Foundation Inc. has adopted the subrecipient monitoring policy of NRG Oncology that comports with the “Subrecipient Compliance With Uniform Administrative Requirements, Cost Principles, and Audit Requirements.” Additionally, activity of subrecipients of the Foundation, including the American College of Radiology (ACR) is monitored under the Management Services Agreement with the NSABP Foundation, via routine analysis and documentation of ongoing activities as well as inspection of ACR financial statements to ensure compliance with 2 CFR 200.322. Lastly, RTOG has created an SOP and document templates to assist in the monitoring of subrecipients.
Method of Implementation - School District personnel will continue to work closely with the Food Service Director to determine the needs of the District in an effort to reduce year end net cash resources. Person Responsible - Director of Food Servcies; Assistant Business Administrator; and Bu...
Method of Implementation - School District personnel will continue to work closely with the Food Service Director to determine the needs of the District in an effort to reduce year end net cash resources. Person Responsible - Director of Food Servcies; Assistant Business Administrator; and Business Administrator/Board Secretary. Implementation Dates - June 30, 2024
2023-005: Inadequate Subrecipient Monitoring Corrective Action: The organization has since implemented additional controls to monitor subrecipients' use of federal awards in 2024. The organization has updated our subgrant agreement to ensure an appropriate monitoring process is included for future c...
2023-005: Inadequate Subrecipient Monitoring Corrective Action: The organization has since implemented additional controls to monitor subrecipients' use of federal awards in 2024. The organization has updated our subgrant agreement to ensure an appropriate monitoring process is included for future cycles. In addition, we have established clear staff roles for monitoring subrecipient reporting compliance including ensuring all subrecipient reports are reviewed and approved through written communication by members of management. Given the additional systems in place, we do not anticipate an issue with subrecipient monitoring and oversight moving forward.
Recommendation: The Center should maintain a checklist of the required annual trainings for each employee and enter the date each training is completed. The Center should be continuously monitoring the trainings during the year to ensure each employee is staying up to date on the requirements. Vie...
Recommendation: The Center should maintain a checklist of the required annual trainings for each employee and enter the date each training is completed. The Center should be continuously monitoring the trainings during the year to ensure each employee is staying up to date on the requirements. View of Responsible Officials and Planned Corrective Actions: The Center agrees with the finding. The Center is in the process of implementing the recommendation.
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to pr...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended June 30, 2023. Finding 2023-001 Responsible Party Name: Myra Cerna Position: Project Accountant Telephone Number: (816) 608-1799 x 259 Federal Agency Department of Housing and Urban Development Federal Program Supportive Housing for Persons with Disabilities (Sec 811) Compliance Requirements A/B - Activities Allowed or Unallowed and Allowable Costs/Cost Principles, C – Cash Management, E – Eligibility, and N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management reported that the failure(s) involved records related to the period managed by the predecessor management company. We will request and keep all required documentation from HUD and establish processes and procedures to ensure compliance with the Regulatory Agreement or Capital Advance Use Agreement. Anticipated Completion Date June 30, 2024
Finding 504244 (2023-006)
Material Weakness 2023
2023-006 - Medical Assistance Program – Children’s Long-Term Support (CLTS) – The County is aware it has not implemented formal controls related to ensuring activities allowed requirements and will take necessary action to implement procedures for compliance. Responsible Official – Beata Haug, PhD –...
2023-006 - Medical Assistance Program – Children’s Long-Term Support (CLTS) – The County is aware it has not implemented formal controls related to ensuring activities allowed requirements and will take necessary action to implement procedures for compliance. Responsible Official – Beata Haug, PhD – CFO Anticipated Completion Date – The County will remedy this in the subsequent fiscal year.
View Audit 326748 Questioned Costs: $1
Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Divi...
Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Division/Office and Individual: • NWYS Housing leadership staff – Luis Reyna, Andy Johnson, Rebecca Pendergraft, Addison Ausley • Finance leadership staff – Stephanie Wagner, Dianne Ersser Estimated Completion Date: 9/30/2024
View Audit 326689 Questioned Costs: $1
Finding 504203 (2023-001)
Material Weakness 2023
Condition: The Organization has engaged a subrecipient as part of this grant program, which was subsequently determined, but did not have an executed agreement with the subrecipient and as a result did not meet the requirements of having performed formal risk assessment procedures. Planned Correctiv...
Condition: The Organization has engaged a subrecipient as part of this grant program, which was subsequently determined, but did not have an executed agreement with the subrecipient and as a result did not meet the requirements of having performed formal risk assessment procedures. Planned Corrective Action: Management has drafted and is finalizing an agreement with the identified subrecipient, and implement formalized policies and procedures to ensure no risk factors for non-compliance exist and to properly monitor the subrecipient activity. The identified subrecipient has met all documentation and submission requirements to support reporting and appropriate usage of grant funds related to the grant program. Contact person responsible for corrective action: Adam Kinder, CFO Anticipated Completion Date: October 11, 2024
1. Implementation of Sage Accounting Software: We have since implemented a comprehensive financial accounting software system, Sage, which allows us to track expenditures more accurately and ensure compliance with federal grant requirements. The system includes built-in safeguards to flag non-compli...
1. Implementation of Sage Accounting Software: We have since implemented a comprehensive financial accounting software system, Sage, which allows us to track expenditures more accurately and ensure compliance with federal grant requirements. The system includes built-in safeguards to flag non-compliant expenditures.
View Audit 326634 Questioned Costs: $1
2. Review and Strengthening of Internal Controls: Life Source International Charter School will be implementing additional internal control systems & processes that include an additional review of back up documents before monthly reports are filed. A copy of all backup documents in support of all m...
2. Review and Strengthening of Internal Controls: Life Source International Charter School will be implementing additional internal control systems & processes that include an additional review of back up documents before monthly reports are filed. A copy of all backup documents in support of all monthly reports will be kept at both Life Source International Charter School and the outside entities providing services and making reports on behalf of Life Source International Charter School.
View Audit 326634 Questioned Costs: $1
3. Staff Training and Capacity Building: Our staff has received training on federal grant compliance, including the specific criteria governing the period of performance and allowable costs under federal awards. Additionally, with the Sage system in place, staff are now better equipped to manage com...
3. Staff Training and Capacity Building: Our staff has received training on federal grant compliance, including the specific criteria governing the period of performance and allowable costs under federal awards. Additionally, with the Sage system in place, staff are now better equipped to manage compliance and reporting accurately.
View Audit 326634 Questioned Costs: $1
4. Commitment to Ongoing Compliance: We are committed to continually improving our internal control processes to ensure compliance with all federal regulations.
4. Commitment to Ongoing Compliance: We are committed to continually improving our internal control processes to ensure compliance with all federal regulations.
View Audit 326634 Questioned Costs: $1
Finding 2023-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Dep...
Finding 2023-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Department of Agriculture Compliance/Internal Control over Compliance: Auditee Responsibilities Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Expenditures of federal awards and not be detected and corrected. Because the Auditee’s SEFA was completed incorrectly, and not reconciled to the general ledger the SEFA was materially misstated, prior to auditors’ correction recommendations.   Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • No reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: October 1, 2024 Responsible Person: Director of Business Services, Yamhill County School District No. 8
FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include proper segregation of duties, that would likely be effective in preventing, or detecting a...
FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include proper segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were complied, prepared and submitted by one employee without documentation to support an oversight or review process in place to prevent, or detect and correct, errors. In addition, because the unit was unable to provide supporting documentation for the information contained in the six reports submitted during the audit period, three of these reports contained errors. Contact Person Responsible for Corrective Action: Kelly McPike Contact Phone Number:765-689-9131 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: An effective internal control will be developed to ensure supporting documentation is used and retained for all required reports submitted on behalf of the Education Stabilization Program Funds. The reports will be compiled, prepared, and submitted by more than one employee to support any possible oversight or errors. Anticipated Completion Date: April 2024
FINDING 2023-004 Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Summary of Finding: The School Corporation had not designed or implemented internal controls, policies, or procedures to ensure that proper procurement procedures for small purchases were followed. Due to th...
FINDING 2023-004 Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Summary of Finding: The School Corporation had not designed or implemented internal controls, policies, or procedures to ensure that proper procurement procedures for small purchases were followed. Due to the lack of oversight or implemented controls small purchases paid to eight vendors totaling $180,015 were made without obtaining price or rate quotes. The School Corporation had not designed or implemented internal controls, policies, or procedures to ensure that vendors were not suspended or debarred prior to entering into a covered transaction. One covered transaction that equaled or exceeded $25,000 was identified and selected for testing. Transactions to the vendor totaled $81,295; the School Corporation did not verify the vendor’s suspension and debarment status prior to payment. Contact Person Responsible for Corrective Action: Juli Windsor Contact Phone Number:765-689-9131 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The corporation will have adequate internal control in place and the corporation will develop a procedure to ensure rate or priced quotes are obtained for small purchases and ensure contractors are not suspended, debarred, or otherwise excluded prior to entering into any contracts or subawards. Anticipated Completion Date: April 2024
FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting...
FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance related to the eligibility determination of a child receiving meals. The School Corporation could not provide documentation supporting the eligibility for 10 of 40 students that received free or reduced-price meals for fiscal year 2022-2023. Of the 30 students for which documentation was provided, the School Corporation could not provide documentation that the one student’s benefits were calculated properly. Due to the lack of supporting documentation we were unable to determine the School Corporation's compliance with the Eligibility compliance requirement. Contact Person Responsible for Corrective Action: Juli Windsor Contact Phone Number:765-689-9131 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: This will include all reimbursements which are submitted to the treasurer must be signed by the school cafeteria managers and the food service director. The school will also implement policies to ensure that the Verification of Free and Reduced-Price applications have an adequate internal control to ensure the validity of the free and reduced applications. This will provide for segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place. Anticipated Completion Date: April 2024
Management agrees with the finding. Management has drafted a procurement policy, and will enact and enforce this policy by the end of 2024. This policy will be reviewed annually to ensure that any changes in laws and regulation are reflected in internal procedures.
Management agrees with the finding. Management has drafted a procurement policy, and will enact and enforce this policy by the end of 2024. This policy will be reviewed annually to ensure that any changes in laws and regulation are reflected in internal procedures.
Management Response/Corrective Action Plan: Additional reports will be run to verify totals before filings of quarterly reports, paying particular attention to end of year and the needed reversal of the prior year payroll accrual. Errors found in reports will be corrected in subsequent records as al...
Management Response/Corrective Action Plan: Additional reports will be run to verify totals before filings of quarterly reports, paying particular attention to end of year and the needed reversal of the prior year payroll accrual. Errors found in reports will be corrected in subsequent records as allowable under Department of Treasury grant reporting guidelines.
Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The fraudster has been convicted and is incarcerated. The Organization has since implemented stronger internal controls to prevent and detect future occurrences of fraud or error. Name(s) of Responsible ...
Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The fraudster has been convicted and is incarcerated. The Organization has since implemented stronger internal controls to prevent and detect future occurrences of fraud or error. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date Already implemented.
Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will update its property records to include all required information. Additionally, the Organization plans to complete a physical inventory count and related reconciliation on an annual ...
Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will update its property records to include all required information. Additionally, the Organization plans to complete a physical inventory count and related reconciliation on an annual basis. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date October 31, 2024
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