Corrective Action Plans

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Single Audit – Federal Funds Finding Organization: Pathways In Education – Illinois (PIE-IL) Audit Period: FY25 (or applicable fiscal year) Prepared By: [Brittany Barsevick/Manager of Instructional Compliance] Date: [1/21/2026] Federal Program: ALN 84.010 Title I, Part A, Basic grants Low-Income and...
Single Audit – Federal Funds Finding Organization: Pathways In Education – Illinois (PIE-IL) Audit Period: FY25 (or applicable fiscal year) Prepared By: [Brittany Barsevick/Manager of Instructional Compliance] Date: [1/21/2026] Federal Program: ALN 84.010 Title I, Part A, Basic grants Low-Income and Neglected Audit Finding Reference: 2025-001 ________________________________________ 1. Finding Summary The Single Audit identified a deficiency in the documentation and communication of federally funded position percentages and the alignment of Time & Effort attestations with the actual period of work performed. Specifically, the current CPS Federal Funds platform (Oracle) generates Time & Effort Attestation reports based on the month reimbursement claims are submitted, rather than the period during which the work was performed, creating a compliance gap. ________________________________________ 2. Root Cause ● Staff were not consistently informed of the exact percentage of their position funded by federal sources at the start of each semester. ● Time & Effort attestations were generated from the CPS Oracle system based on claim submission timing, not the actual work period. ● There was no formal internal SOP layer to supplement Oracle-generated reports with staff attestation aligned to Semester 1 and Semester 2 work periods. ________________________________________ 3. Corrective Actions Action 1: Internal Funding Percentage Notification System Description: PIE-IL will implement an internal tracking and notification system to ensure all staff funded in whole or in part with federal funds are formally notified of the exact percentage of their position supported by federal funding. Implementation Steps: ● Develop a standardized Federal Funding Allocation Notice template. ● Distribute notices to all applicable staff at the start of Semester 1 and Semester 2. ● Require staff acknowledgment (electronic or signed) confirming receipt and understanding. ● Maintain records centrally in the federal compliance folder. Responsible Party: Manager of Instructional Compliance Timeline: Implemented by the first day of each semester Monitoring: Semester-based review of acknowledgment logs ________________________________________ Action 2: Semester-Based Time & Effort Attestation Description: All federally funded staff will complete and sign a Time & Effort Attestation for both Semester 1 and Semester 2, certifying that time worked aligns with the funding source and percentage assigned. Implementation Steps: ● Issue Time & Effort forms at the end of each semester. ● Require staff to certify actual work performed during the semester. ● Collect supervisor verification signatures. ● Store completed attestations in the federal compliance repository. Responsible Party: Site Administrators / Federal Compliance Officer Timeline: Within 10 business days of semester end Monitoring: Quarterly internal compliance audits ________________________________________ Action 3: Internal SOP as Supplemental Documentation Layer Description: PIE-IL will implement a formal Standard Operating Procedure (SOP) for Time & Effort as a self-managed, internal documentation layer that supplements CPS Oracle-generated attestation reports. This SOP will ensure that Time & Effort documentation reflects the actual period of work performed, rather than the month in which reimbursement claims are submitted. Implementation Steps: ● Draft and approve a written SOP outlining: ○ Semester-based attestation requirements ○ Alignment between funding percentages and staff assignments ○ Reconciliation process between internal records and Oracle reports ● Train administrators and federally funded staff on SOP procedures. ● Maintain SOP as a controlled document with annual review and updates. Responsible Party: Federal Programs Director / Compliance Manager Timeline: SOP finalized within 30 days of audit response submission Monitoring: Annual SOP review and internal compliance testing ________________________________________ 4. Reconciliation Process with CPS Oracle System PIE-IL will perform a monthly reconciliation between: ● Oracle-generated Time & Effort Attestation reports (claim-based), and ● Internal Semester-Based Time & Effort attestations (work-period-based). Any discrepancies will be documented, corrected, and reviewed by the Federal Compliance Officer prior to reimbursement submission. ________________________________________ 5. Evidence of Implementation The following documentation will be maintained for audit and monitoring purposes: ● Federal Funding Allocation Notices with staff acknowledgments ● Signed Semester 1 and Semester 2 Time & Effort Attestation forms ● Approved Time & Effort SOP document ● Training sign-in sheets and materials ● Monthly reconciliation logs between Oracle and internal records ________________________________________ 6. Completion Dates Corrective Action Target Completion Date Funding Percentage Notification System [9/30/2026] Semester-Based Time & Effort Attestation Process [02/06/2026] SOP Finalization and Staff Training [02/28/2026] Monthly Reconciliation Process Ongoing ________________________________________
The Academies will implement a monitoring system to ensure there are no clerical errors recording data in the system.
The Academies will implement a monitoring system to ensure there are no clerical errors recording data in the system.
Corrective Action Plan: Management agrees with the finding. The City had a preexisting agreement with the subrecipient for a project that was already in progress when the federal grant was awarded. The subrecipient had in-depth involvement during the federal grant application process and is aware of...
Corrective Action Plan: Management agrees with the finding. The City had a preexisting agreement with the subrecipient for a project that was already in progress when the federal grant was awarded. The subrecipient had in-depth involvement during the federal grant application process and is aware of specific compliance requirements under the Uniform Guidance (2CFR Part 200). We will make sure that all future subrecipients of pass-through federal grants are notified in writing of the responsibility to adhere to federal administrative, cost, and audit requirements.
Subject: Special Education Cluster (IDEA) - Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Cluster Assistance Listing Number: 84.027, 84.027X Federal Award Year (or Other Identifying Numbers): 22611-023-PN01, 22611-023-ARP, 23611-023-PN01 , 24611-...
Subject: Special Education Cluster (IDEA) - Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Cluster Assistance Listing Number: 84.027, 84.027X Federal Award Year (or Other Identifying Numbers): 22611-023-PN01, 22611-023-ARP, 23611-023-PN01 , 24611-023- PN01 , 25611-023-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Suspension and Debarment Audit Findings: Significant Deficiency Condition: An effective system of internal controls was not in place at the School Corporation to ensure the HamiltonBoone- Madison Special Education Cooperative's compliance with applicable requirements related to the Special Education Cluster (IDEA), specifically with respect to Suspension and Debarment requirements. No instances of noncompliance (entering a contract with a vendor that was suspended or debarred) were identified in the transactions selected for testing. The matter represents a deficiency in internal controls over the Suspension and Debarment process, rather than identified noncompliance with program requirements. Context: Suspension and Debarment As part of its internal control procedures, the Cooperative utilizes the System for Award Management (SAM.gov) to verify the eligibility status of vendors prior to engaging in financial transactions. This verification process is designed to ensure that vendors are not suspended, debarred, or otherwise excluded from participation in federal programs, in accordance with applicable procurement regulations. Three covered transactions that equaled or exceeded $25,000 were identified. Of the three transactions, all were selected for testing, totaling $141,578. The Cooperative did not verify the vendors' suspension and debarment status prior to payment for two of the three covered transactions. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will enhance oversight of the Hamilton-Boone-Madison Special Education Cooperative's procurement process to ensure all applicable procurement steps, including suspension and debarment checks, are completed and follow federal regulations for the program, prior to entering into a contract with the respective vendor. Responsible Party and Timeline for Completion: David Hortemiller, CFO and Susan Wilson, Director of Finance met with Steven Wornhoff, Director of HBM Cooperative and Kim Kuersteiner, HBM Technology Manager to establish a process to review all vendors for suspension and debarment. Training was provided in regard to the Sam.gov website. Since August 2024, the Hamilton-Boone-Madison Special Services Cooperative (the Cooperative) has used the System for Awards Management (SAM.gov) to verify the eligibility status of vendors prior to engaging in financial transactions. The Cooperative will continue to use this process for any transaction equaling or exceeding $25,000. Documentation of the verification process will be retained by the Cooperative.
The College will diligently check each financial aid disbursement roster to review and refund any student account credit balances generated from a disbursement. This process is to maintain compliance with this requirement. The College will also create an Infomaker report each week to identify any cr...
The College will diligently check each financial aid disbursement roster to review and refund any student account credit balances generated from a disbursement. This process is to maintain compliance with this requirement. The College will also create an Infomaker report each week to identify any credit balances that need refunded.
Financial Aid personnel responsible for loan disbursements will review both COD and Pfaid records to ensure they align with the corresponding student account disbursement information. Additionally, the office will conduct monthly COD mismatch reviews to determine whether maintenance files need to be...
Financial Aid personnel responsible for loan disbursements will review both COD and Pfaid records to ensure they align with the corresponding student account disbursement information. Additionally, the office will conduct monthly COD mismatch reviews to determine whether maintenance files need to be submitted. This process will help ensure continued accuracy and compliance in federal reporting.
All Financial Aid personnel were re-trained on the SEOG minimum and maximum award parameters. The office will conduct quarterly reviews of awards to ensure compliance and verify that no students are incorrectly awarded.
All Financial Aid personnel were re-trained on the SEOG minimum and maximum award parameters. The office will conduct quarterly reviews of awards to ensure compliance and verify that no students are incorrectly awarded.
The Organization will reinforce its filing control environment by implementing a documented reporting calendar and assigning responsibility to finance leadership for reviewing and certifying timely submission of future single audit reporting packages.
The Organization will reinforce its filing control environment by implementing a documented reporting calendar and assigning responsibility to finance leadership for reviewing and certifying timely submission of future single audit reporting packages.
Views of Responsible Officials and Planned Corrective Actions – The CFO and Student Accounts Manager will provide a listing of all students receiving a refund. A grace period of 5 days for students to provide direct deposit information will be established, if after 5 there is still no direct deposit...
Views of Responsible Officials and Planned Corrective Actions – The CFO and Student Accounts Manager will provide a listing of all students receiving a refund. A grace period of 5 days for students to provide direct deposit information will be established, if after 5 there is still no direct deposit information, a check will be issued.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure notification to federally funded employees of their funding source twice a year and will make sure supervisors get reports and sign certifications for work duties in compliance with the federal grants twice a year. Date of implementation - effective immediatel...
The Chief Financial Officer will ensure notification to federally funded employees of their funding source twice a year and will make sure supervisors get reports and sign certifications for work duties in compliance with the federal grants twice a year. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
Congressional Directives – Assistance Listing No. 93.493 Recommendation: We recommend CAPECO ensure documentation is retained to support the date the suspension and debarment verification procedures are performed. Explanation of disagreement with audit finding: There is no disagreement with the audi...
Congressional Directives – Assistance Listing No. 93.493 Recommendation: We recommend CAPECO ensure documentation is retained to support the date the suspension and debarment verification procedures are performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CAPECO will obtain time-stamped verification support from SAM.gov to ensure that potential contractors are free from debarment and suspension prior to executing the contract. Name(s) of the contact person(s) responsible for corrective action: Paula Hall, CEO and/or Katie Smith, CFO Planned completion date for corrective action plan: Effective Immediately
2025-002 Finding – Federal Funding Accountability and Transparency Act (FFATA)/Transparency Act Reporting (Timeliness) Federal Agency: U.S. Department of Health and Human Services (HHS) Program: Head Start Cluster – Assistance Listing 93.600 (Head Start) Compliance Requirement: Reporting (L) – FFATA...
2025-002 Finding – Federal Funding Accountability and Transparency Act (FFATA)/Transparency Act Reporting (Timeliness) Federal Agency: U.S. Department of Health and Human Services (HHS) Program: Head Start Cluster – Assistance Listing 93.600 (Head Start) Compliance Requirement: Reporting (L) – FFATA/Transparency Act Special Reporting Type of Finding: Compliance (no internal control deficiency) Finding Summary: Two first-tier subaward actions were submitted in SAM.gov after the required reporting timeframe. Based on the nature of the exceptions and the results of expanded procedures, the late submissions appear to be isolated to the period of the federal FSRS-to-SAM.gov transition rather than indicative of a systemic reporting breakdown. Management attributed the delays to federal system conversion issues, including access/role challenges, delayed training, and data migration/report rejection issues that required resolution with SAM.gov support. Accordingly, the noncompliance is limited to timeliness of transparency reporting (no questioned costs) and does not affect allowability of Head Start expenditures. Corrective Action Plan: Delays were primarily attributable to the federal transition from FSRS to SAM.gov, including access/role configuration challenges and system-related issues encountered during the conversion period. Reasonable and timely steps were taken to submit the required FFATA reports as soon as the federal system issues were resolved and to address any submission rejections or support requests as needed. Now that the filing of back logged reports is complete, we will continue with our existing FFATA reporting procedures. We will track contracts needing FFATA submission with an internal ticketing system to ensure that the filings are on time. We will retain appropriate documentation of submissions and related system communications to support compliance. We will submit said documentation to our business office as a secondary measure to ensure that the filing was done prior to processing said contract. Contact Person responsible for corrective action: Anthony Jordan, Division Director Anticipated completion date of Corrective Action Plan: This item is corrected as of 10/01/2025.
Response and Corrective Action Plan prepared by: Leanne Green Person Responsible for Implementing the Corrective Action: Leanne Green Anticipated Completion Date of Corrective Action: Vickie Dunaway, School Nutrition Director, corrected and resubmitted the claim in question, as soon as the issue was...
Response and Corrective Action Plan prepared by: Leanne Green Person Responsible for Implementing the Corrective Action: Leanne Green Anticipated Completion Date of Corrective Action: Vickie Dunaway, School Nutrition Director, corrected and resubmitted the claim in question, as soon as the issue was revealed. USDA paid the difference owed on October 28, 2025. Planned Corrective Action: Once the School Nutrition Director completes the monthly claim, Leanne Green, Finance Director, reviews the paperwork, verifying that all is correct before the claim is filed.
Corrective Action Plan 2025-001: The College concurs with the finding and has adjusted its processes and controls beginning with the Fall 2025 semester to ensure that all Title IV funding sources including FSEOG are drawn down in accordance with the Heightened Cash Monitoring requirements. Completio...
Corrective Action Plan 2025-001: The College concurs with the finding and has adjusted its processes and controls beginning with the Fall 2025 semester to ensure that all Title IV funding sources including FSEOG are drawn down in accordance with the Heightened Cash Monitoring requirements. Completion Date: August 2025 Contact Person: Laura Crawley
The City will (1) submit the required FFATA subaward reports for the five unreported tier one subawards, (2) implement a formal FFATA compliance checklist to be completed at the time of subaward execution, (3) designate responsible personnel for FSRS reporting with a documented secondary review, and...
The City will (1) submit the required FFATA subaward reports for the five unreported tier one subawards, (2) implement a formal FFATA compliance checklist to be completed at the time of subaward execution, (3) designate responsible personnel for FSRS reporting with a documented secondary review, and (4) provide training to applicable staff on FFATA reporting requirements and deadlines.
Finding 2025.001 Special Tests and Provisions - Sliding Fee Discounts Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken: Effective February 9,...
Finding 2025.001 Special Tests and Provisions - Sliding Fee Discounts Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken: Effective February 9, 2026, we will implement the following changes to ensure clients are appropriately charged according to the sliding fee scale. -Update the frequency of our sliding fee scale employee training sessions -Implement monthly spot checks to ensure compliance to the sliding fee scale and provide timely feedback
PLANNED CORRECTIVE ACTIONS PLANNED: The Organization acknowledges the finding and agrees with the recommendation. The Organization also notes that the percentage of adults maintaining or increasing income was impacted by several participants exiting the program near the end of the fiscal year. Due t...
PLANNED CORRECTIVE ACTIONS PLANNED: The Organization acknowledges the finding and agrees with the recommendation. The Organization also notes that the percentage of adults maintaining or increasing income was impacted by several participants exiting the program near the end of the fiscal year. Due to their shorter timeframe in the program, these participants had limited opportunity to achieve employment goals or secure increased income. The Organization will review program exit timing and case planning procedures to better ensure participants have adequate time to engage in employment-related services before exit, when possible. To address the finding and improve future performance, the Organization is implementing the following corrective actions: 1. Improved Income-Tracking System: A revised income-tracking process will be integrated into case-management to ensure income information is consistently updated at program entry, during routine case reviews, and at exit. 2. Enhanced Staff Training: Case managers and program staff will receive updated training on income documentation requirements, including timely data entry and verification procedures. 3. Quarterly Internal Monitoring: The Finance Manager will conduct quarterly reviews of participant files to ensure accurate income tracking and identify areas needing corrective attention. 4. Program Exit and Case Planning Adjustments: Program leadership will work with case managers to strengthen exit planning protocols, helping ensure participants have sufficient time to pursue employment goals before program completion whenever possible. 5. Regular Coordination Between Finance and Program Teams: Monthly cross-departmental check-ins will be established to keep financial and program data aligned and identify issues early.
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to...
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to work to enhance our grant monitoring, including resuming management team meetings to keep everyone abreast of the status of grants. In addition, we will begin to gradually involve the new business office employee in grant reporting to improve on compliance with grant reporting requirements. Proposed Completion Date: June 30, 2026
Action Taken: Management agrees with the recommendations and will contact the Pennsylvania Department of Education to inquire as to how to resubmit the annual report with correct amounts for 2023-24, agreeing the expenditures to the District’s books and records. In addition, the business manager wil...
Action Taken: Management agrees with the recommendations and will contact the Pennsylvania Department of Education to inquire as to how to resubmit the annual report with correct amounts for 2023-24, agreeing the expenditures to the District’s books and records. In addition, the business manager will ensure the amounts reported for the upcoming annual report for fiscal year 2024-25 contain the correct expenditures and that the expenditures agree with the District’s books and records. Proposed Completion Date: March 31, 2026
Action Taken: Management agrees with the recommendations. The unique situation with the COVID-19 funding, coupled with shifts in the business manager’s duties over the last few years and the staff retirement has resulted in grant report filings becoming a lower priority. The management team will wor...
Action Taken: Management agrees with the recommendations. The unique situation with the COVID-19 funding, coupled with shifts in the business manager’s duties over the last few years and the staff retirement has resulted in grant report filings becoming a lower priority. The management team will work together and will resume management team meetings to determine and monitor the duties for which each is responsible. Strides have been made in this regard, as the principals have become involved in Federal program training, budgeting, and scheduling. Although the aforementioned report submissions are delinquent and funding was suspended, some filings have been completed, and certain payments have been received and others are forthcoming. However, management will begin to gradually involve the new business office employee in grant reporting to improve on compliance with grant reporting requirements. Proposed Completion Date: June 30, 2026
Views of Responsible Officials and Corrective Action Plan The District agrees with the finding and will implement procedures that will ensure Returns of Title IV funds are returned no later than 45 days after that date the College determines the student has withdrew.
Views of Responsible Officials and Corrective Action Plan The District agrees with the finding and will implement procedures that will ensure Returns of Title IV funds are returned no later than 45 days after that date the College determines the student has withdrew.
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