Corrective Action Plans

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Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.
Finding 2023-001: The Corporation did not obtain a HUD approved management certification (HUD Form 9839-B) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management certification should be submitted to HUD for retroactive app...
Finding 2023-001: The Corporation did not obtain a HUD approved management certification (HUD Form 9839-B) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management certification should be submitted to HUD for retroactive approval for the period beginning September 1, 2023. Action(s) Taken or Planned on the Finding: The Corporation concurs with the recommendation and will submit the management certification to HUD for approval retroactively.
View Audit 323052 Questioned Costs: $1
View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accountin...
View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.
Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward o...
Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward or downward—to ensure it accurately reflects our current cost structure. To maintain compliance and integrity in our financial processes, the Technical and Internal Controls Accountant will oversee the review of costs included in the indirect cost pool to ensure they meet the criteria for allowability. Additionally, this role will involve verifying that invoices utilize the most current indirect cost recovery rate. Furthermore, management will prepare and submit the required indirect cost proposal to the appropriate cognizant agency to finalize our provisional billing rates used in fiscal year 2023, that aligns with our operational needs and complies with federal guidelines. This proactive approach will strengthen our financial management practices and support our ongoing commitment to transparency and accountability in the administration of federal grants.
View Audit 323015 Questioned Costs: $1
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallo...
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization requested drawdowns of grant funds in excess of amounts awarded for the grant years ended 10/31/2023 and 10/31/2022 that were denied by the passthrough agency, Omaha Public Schools, resulting in an overstatement in grant revenue and receivables, and federal awards expended included in the schedule of expenditures of federal awards. Corrective Action Plan: Management is in the process of reviewing its accounting policies and procedures over grant monitoring to ensure amounts are tracked appropriately. Management has hired a new fiscal services director to oversee this process. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024
View Audit 322999 Questioned Costs: $1
Finding 2023-002 Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Subrecipient Monitoring Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting The Foundation developed a matrix for subrecipient monitoring an...
Finding 2023-002 Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Subrecipient Monitoring Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting The Foundation developed a matrix for subrecipient monitoring and Single Audit reports/findings is a key attribute in our assessment of risk. Our subrecipient monitoring policy and procedure was completed on November 30, 2023. Additionally, we hired a Program Coordinator in June 2023. The Program Coordinator focuses on the interface work required by our organization to support our grants administration role including subrecipient monitoring The Foundation requires quarterly progress and financial reports from our subrecipients, and our current process is to increase scrutiny of reports and supporting documents, when risk is medium or high. The Foundation performed reviews of subrecipients in 2023, however, the time stamp was not effectively documented. The Foundation has implemented procedures to effectively time stamp the verification process using Sam.gov going forward. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024
Finding 500133 (2023-005)
Significant Deficiency 2023
This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time fra...
This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/ petitions to case files and file documentation beginning in November 2023.
Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training t...
Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.
This finding occurred as a result of a data entry error in the file. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in No...
This finding occurred as a result of a data entry error in the file. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Hu...
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Human Services department will complete the reconciliation of the service providers costs reports for the fiscal year ended June 30, 2024 before March 2025.
The County Human Services department will complete the Roster of Personnel (PW 1171) be submitted for the fiscal year ended June 30, 2023 by December 2024 and review the processes and controls to ensure the rosters is completed annually.
The County Human Services department will complete the Roster of Personnel (PW 1171) be submitted for the fiscal year ended June 30, 2023 by December 2024 and review the processes and controls to ensure the rosters is completed annually.
The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report...
The County Human Services department has requested approval from PA DHS of its 2021-2022 fiscal year re-submission in September 2024. Following approval of the 2021-2022 submission and re-investment the County Human Services department will complete the submission of the 2022-2023 fiscal year report. The County Human Services department will reconcile the underlying expenditure detail in the accounting system to the expenditures reported. Internal approvals prior to submission and underlying records for reports will be maintained by the County Human Services department.
Finding 500121 (2023-006)
Significant Deficiency 2023
The County Child and Youth Services department started requiring a corrective action plan for all subrecipients with findings as a result of their on-site monitoring in 2023 that include the entity’s plan to correct the errors noted, individual responsible and timeline for corrections to be implemen...
The County Child and Youth Services department started requiring a corrective action plan for all subrecipients with findings as a result of their on-site monitoring in 2023 that include the entity’s plan to correct the errors noted, individual responsible and timeline for corrections to be implemented. Finding noted are for monitoring completed in January and March 2023, prior to the requirement of written corrective action plans being implemented.
2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent w...
2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent with Uniform Guidance. Personnel responsible for procurement should be trained on Uniform Guidance requirements and Centro Hispano's written procurement procedures. Action Taken: Centro Hispano drafted and approved an Accounting Policies and Procedures manual in September 2024 which conforms with Uniform Guidance requirements.
View Audit 322967 Questioned Costs: $1
Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allo...
Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allocated into the correct funds as approved by the Township Board. Contact person responsible for corrective action: Molly Phillips and Katelyn Massey Anticipated Completion Date: 12/31/2024
Currently the Columbus Housing Authority is responding to your findings as it relates to the fiscal year December 2023. We are addressing the audit findings related to financial statement missed FDS submission deadline for the unaudited financials and the Authority interfund receivables and payables...
Currently the Columbus Housing Authority is responding to your findings as it relates to the fiscal year December 2023. We are addressing the audit findings related to financial statement missed FDS submission deadline for the unaudited financials and the Authority interfund receivables and payables balance that have not been repaid as of the fiscal year end. The following corrective actions will be implemented as it relates to the findings: The following steps will be taken regarding the financial statement FDS submission and interfund repayment: Financial Statements 1. Understand Deadlines: Become familiar with the submission deadlines for both unaudited and audited financial data. 2. Create a Timeline: Develop a detailed timeline that includes all key dates and milestones leading up to the submission deadline. This will include internal review periods and time for corrections. 3. Assign Responsibilities: Clearly define roles and responsibilities within our team to ensure that each part of the submission process is covered. 4. Regular Check-ins: Schedule regular check-ins to monitor progress and address any issues that may arise early on. 5. Use HUD Tools: Utilize HUD’s FDS Submission Upload Tool and other resources to streamline the data entry and submission process. 6. Perform Completeness Checks: Before submitting, perform a submission completeness check to ensure all required data is accurate and complete. 7. Request Extensions if Needed: If we encounter unusual circumstances that may delay our submission, request an extension as early as possible. 8. Backup and Documentation: Keep backups of all submitted data and maintain thorough documentation of the submission process for future reference. Interfund Repayment 1. Identify Interfund Transaction: List all interfund transactions, this includes payables, payroll, reimbursements, and etc. 37 2. Record Transaction: Ensure all interfund transactions are recorded in the general ledger. 3. Reconcile Balances: Reconcile the balances of all interfund accounts between each fund. 4. Investigate Discrepancies: Investigate and resolve any discrepancies found during the reconciliation process. Make the necessary adjusting entries to correct any errors or discrepancies identified. 5. Documentation: Maintain thorough documentation for all interfund transactions. Additionally, regular monitoring and periodic review of the effectiveness of the implemented controls will be conducted to ensure ongoing compliance and continuous improvement.
Corrective Action Planned: We will review the Uniform Guidance Standards and update the procedures needed to be in full accordance. Name(s) of Contact Person(s) Responsible for Corrective Action: Lynette Bacchus will make the changes and John Pinto and Lawrence Boord will approve. Anticipated Com...
Corrective Action Planned: We will review the Uniform Guidance Standards and update the procedures needed to be in full accordance. Name(s) of Contact Person(s) Responsible for Corrective Action: Lynette Bacchus will make the changes and John Pinto and Lawrence Boord will approve. Anticipated Completion Date: October 31, 2024.
Finding 500113 (2023-002)
Significant Deficiency 2023
In responding to the findings of the audit regarding the absence of a documented procurement policy that aligns with federal statutes and procurement requirements as outlined in 2 CFR Part 200, Sigma Beta Xi, Inc. acknowledges the criticality of this oversight. We understand the importance of having...
In responding to the findings of the audit regarding the absence of a documented procurement policy that aligns with federal statutes and procurement requirements as outlined in 2 CFR Part 200, Sigma Beta Xi, Inc. acknowledges the criticality of this oversight. We understand the importance of having formal, documented policies in place to guide our procurement processes, ensuring they are transparent, equitable, and in full compliance with federal regulations. The absence of such documentation represents a missed opportunity for our organization to institutionalize best practices and safeguard the integrity of our procurement activities. Corrective Actions and Commitments: Please let it be known prior to completion of our 2023 audit we were still in the process of finalizing our 2022 audit. Therefore, it was not a matter of willful intention in not being compliant with the Federal mandated guidance policy for Procurement and Suspension and Debarment, but a matter of timing. Research of our vendors was in the process for 2023, but documentation of the research was not being recorded. To address this finding and prevent future occurrences, Sigma Beta Xi, Inc. has taken the following steps: 1. Policy Development: We are in the process of developing a comprehensive procurement policy that will be fully documented and accessible. This policy will outline the procedures for all procurement activities, ensuring they are consistent with the requirements set forth in 2 CFR sections 200.318 through 200.326. It will reflect applicable state and local laws and regulations, as well as conform to applicable federal statutes and procurement requirements. 2. Stakeholder Engagement: Recognizing the importance of stakeholder buy-in, we will involve key personnel from various departments in the development of the procurement policy. This collaborative approach ensures the policy is comprehensive, practical, and adheres to the diverse needs of our organization while maintaining compliance with federal regulations. 3. Training and Implementation: Upon completion and approval of the procurement policy, we will conduct training sessions for all relevant staff. These sessions will cover the details of the policy, emphasizing the importance of compliance with federal statutes and the procurement requirements identified in 2 CFR Part 200. This will ensure that all team members are knowledgeable about the policy and understand their roles and responsibilities within the procurement process. 4. Monitoring and Compliance: We will establish mechanisms for monitoring compliance with the new procurement policy. This includes regular audits of procurement activities and ongoing reviews of the policy to ensure it remains current with federal regulations and best practices. 5. Documentation and Transparency: All procurement activities, especially those exceeding the simplified acquisition threshold, will be thoroughly documented, including the rationale for the procurement method used, selection of contract type, contractor selection or rejection, and the basis for the contract price. This documentation will ensure transparency and accountability in our procurement processes. Sigma Beta Xi, Inc. is committed to rectifying this deficiency by not only developing and implementing a documented procurement policy but also by fostering a culture of compliance and continuous improvement. We view the audit findings as an opportunity to enhance our operational effectiveness and ensure that our procurement practices fully support our mission to break the cycle of poverty and violence through mentoring, education, and community organizing. Our dedication to upholding the highest standards of integrity and transparency in all our operations is unwavering, as we continue to empower future professional leaders in every community we serve.
Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal...
Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal control or procedure manuals include all of the required compliance requirements. We also recommend that the City ensure multiple individuals are trained on the administration of the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz Planned completion date for corrective action plan: 10/14/2024
Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment an...
Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment and monitoring that are in place from the Research department. We will leverage key resources within the organization to address areas of noncompliance. Responsible Official: Ashlee Jean Roffe, Director of Nutrition and Community Health, Community CARE
View Audit 322924 Questioned Costs: $1
Finding 499966 (2023-002)
Significant Deficiency 2023
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No.21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal. Explanation of Disagreement with Audit Finding: There is no disagreemen...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No.21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The Town agrees that suspension and debarment documentation was not properly kept. The Town has met with their legal counsel to update all contract templates to include a clause or conidiation regarding suspension and debarment. This review will be completed by the finance department prior to entering into the contact with each entity. The documentation should include the certification from the vendor or reference the contract that includes the clause or condition regarding suspension and debarment. Name of the Contact Person Responsible for Corrective Action: Sara Hancock, Finance Director Planned Completion Date for Corrective Action Plan: The checklist for compliance has already been put in place for confirming a vendor is compliant. The Town’s legal counsel will provide templates no later than December 2024. If the Department of the Treasury has questions regarding this plan, please call Sara Hancock, Finance Director at 303-926-2750.
FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The Town's policies related to SLFRF suspension and debarment requirement did not include checking the EPL...
FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The Town's policies related to SLFRF suspension and debarment requirement did not include checking the EPLS for vendor suspension and debarment. All three covered transactions tested did not have documentation provided to show the vendor was checked for suspension and debarment. Additionally, the Town did not have a formalized procurement policy outlining its processes and procedures with regards to the procurement of goods and services using federal grant funds. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will be more diligent in finding out if our grants are federal and what requirements they have for us to follow. We will check applicable vendors for suspension and debarment and implement a control/review over those searches. Anticipated Completion Date: November 1, 2024
Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal au...
Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal audits. Person(s) Responsible: Sandi Weiss, AVP Finance Expected Completion Date: November 15, 2024
View Audit 322865 Questioned Costs: $1
Finding 499909 (2023-001)
Significant Deficiency 2023
Name of Contact Person Responsible for Corrective Action: John Hunt Centra Health Corporate Director, Information Security and Disaster Recovery 561-613-7342 john.hunt@centrahealth.com Anticipated Completion date: December 31, 2024 Corrective Action: 2023-001 – Special tests and provisions:...
Name of Contact Person Responsible for Corrective Action: John Hunt Centra Health Corporate Director, Information Security and Disaster Recovery 561-613-7342 john.hunt@centrahealth.com Anticipated Completion date: December 31, 2024 Corrective Action: 2023-001 – Special tests and provisions: To assure compliance with GLBA requirements, Centra is partnering with a third-party vendor to conduct a full GLBA risk assessment in FY2024 and will document safeguards for any identified risks. Additionally, Centra has hired dedicated staff for coordinating future risk assessments and will conduct an annual risk assessment that addresses the three required areas noted in 16 CFR 314.4 (b), will document safeguards for any identified risks, and will regularly test, monitor, and adjust safeguards, as needed.
Finding 499887 (2023-003)
Material Weakness 2023
FINDING 2023-003 Finding Subject: Suspension and Debarment Summary of Finding: Due to the lack of effective internal controls, Suspension and Debarment requirements were not met during the audit period. Contact Person Responsible for Corrective Action: Shelley Mawhorter, County Auditor Contact Phone...
FINDING 2023-003 Finding Subject: Suspension and Debarment Summary of Finding: Due to the lack of effective internal controls, Suspension and Debarment requirements were not met during the audit period. Contact Person Responsible for Corrective Action: Shelley Mawhorter, County Auditor Contact Phone Number and Email Address: (260) 636-2658; shelley.mawhorter@nobleco.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Noble County Auditor’s office will implement effective internal controls in reference to Suspension and Debarment requirements related to subawards and covered transactions to ensure that one of the three allowable methods of verifying that a vendor is not suspended or debarred is completed prior to entering into the contract or transaction. Anticipated Completion Date: We will have the Corrective Action Plan implemented by December 31, 2024.
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