Corrective Action Plans

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The Pennsylvania Department of Agriculture, Bureau of Food Assistance is in the process of developing a procedure to ensure that a report of review findings is submitted to each eligible agency after their review. This procedure will also ensure that, if the review resulted in findings that require ...
The Pennsylvania Department of Agriculture, Bureau of Food Assistance is in the process of developing a procedure to ensure that a report of review findings is submitted to each eligible agency after their review. This procedure will also ensure that, if the review resulted in findings that require implementation of corrective actions, additional monitoring is conducted until the eligible agency has successfully taken actions to mitigate the deficiencies. Anticipated Completion Date: 09/30/2026 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance
Finding 1181238 (2025-001)
Material Weakness 2025
Finding 2025-001 N. Special Tests and Provisions – N6. NSLDS Reporting Identification of the federal program: Federal Grantor: United States Department of Education Federal Cluster: Student Financial Assistance (SFA) Cluster Assistance Listing Nos.: 84.063, Federal Pell Grant Program, and 84.268, Fe...
Finding 2025-001 N. Special Tests and Provisions – N6. NSLDS Reporting Identification of the federal program: Federal Grantor: United States Department of Education Federal Cluster: Student Financial Assistance (SFA) Cluster Assistance Listing Nos.: 84.063, Federal Pell Grant Program, and 84.268, Federal Direct Student Loans Award Period of Performance: July 1, 2024–June 30, 2025 Condition: Internal controls over the review and approval of the enrollment report sent to the third-party servicer, National Student Clearinghouse (NSC), were not adequately designed or operating effectively as follows: • A record count reconciliation between the enrollment report submitted to the NSC and the number of files received by the NSC, and documentation over how any rejected records were addressed, is not performed as part of the internal control. • Details of the validation of student information included in the enrollment report for accuracy prior to being sent to the NSC were not retained by Mercy Health. • Details of the NSC error report and corrections made were not retained by Mercy Health. Views of Responsible Officials and Planned Corrective Actions: 1. Corrective Action: Record Count Reconciliation & Rejected Records • Implement a mandatory, documented reconciliation process for every submission. 2. Corrective Action: Pre-Submission Validation Documentation • Formalize the validation process and retain evidence of accuracy checks. 3. Corrective Action: Retention of NSC Error Reports & Corrections • Establish a procedure for downloading and retaining error reports. By implementing these actions, Southeast Missouri Hospital College of Nursing & Health Sciences will ensure compliance with federal regulations regarding the accuracy and timeliness of student enrollment reporting to the NSC and NSLDS. Responsible Party: Steve Ritter, Registrar and/or Deanna Sells, Business Officer Date of Completion: Phased implementation began in January 2026 and our action plan will be fully implemented as of the March 2026 enrollment reporting process.
FINDING 2025-005 SPED Procurement and Suspension and Debarment Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of...
FINDING 2025-005 SPED Procurement and Suspension and Debarment Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Accounting Department will start keeping a binder that will include all the Procurement and Suspension and Debarment Certificates pertaining to the vendors in our federal programs that equal or exceed $25,000 for each school year. The A/P Clerk will alert the Treasurer when a certificate is needed, and the Treasurer will first check SAM, and then proceed with collecting a certificate from the vendor if one is not found online. When applicable, we can add a clause or condition to a contract noting this acknowledgement. Anticipated Completion Date: This process will be in place by the end of the current fiscal year, June 30, 2026.
FINDING 2025-004 CNC Procurement and Suspension and Debarment Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsib...
FINDING 2025-004 CNC Procurement and Suspension and Debarment Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Accounting Department will start keeping a binder that will include all the Procurement and Suspension and Debarment Certificates pertaining to the vendors in our federal programs, which includes Child Nutrition, that equal or exceed $25,000 for each school year. The A/P Clerk will alert the Treasurer when a certificate is needed, and the Treasurer will first check SAM, and then proceed with collecting a certificate from the vendor if one is not found online. When applicable, we can add a clause or condition to a contract noting this acknowledgement. Anticipated Completion Date: This process will be in place by the end of the current fiscal year, June 30, 2026.
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are follow...
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are following these procedures consistently.
REFERENCE: 2025-101 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2025 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 256AZ003N1199 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of t...
REFERENCE: 2025-101 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2025 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 256AZ003N1199 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Claudia Cordova, Director 2. Corrective action planned: AAFDCP will continue to follow the menu reading policy of reading 100% of all menus/OERS before submitting the Claim to The ADE and of double checking each person’s work by exchanging menus/OERs to include checking for clerical errors and creditable food components. The person reviewing the menus/OERs will initial the form to indicate it has been reviewed. All visit forms will be checked by The Director, Claudia Cordova, Assistant Director Cathy Reagan and Bi-lingual Specialist Veronica Mendoza before entering the data into KidKare to ensure all information is complete and accurate. The initials of the person double checking the form will be added to the bottom of the visit form along with the date it was reviewed. 3. Anticipated completion date: Ongoing process already implemented
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS ...
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS Financial modules. IAM team will establish a documented process through which it will coordinate with the CAPPS Financial team to perform quarterly reviews of accounts and audit logs to strengthen privileged access provisioning. The review process will include documented approval, business justification, and periodic revalidation for all elevated roles in CAPPS Financial. Pathlock software is being used to manage single sign-on for granting privileged access to allowed users. With this software, the IAM team can grant access to a user, who would then login as themselves and then switch to the appropriate privileged role. Once the user switches to a privileged role, the Pathlock software maintains the audit log of user activity. Implementation date: February 27, 2026 Responsible persons: Daniel Kellogg, Deputy Chier Information Officer (DCIO), Infrastructure Services Leatha Marr, DCIO & Chief Product Officer, System Applications
Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to...
Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to federal and state requirements. • Will establish an inventory of systems to ensure information owners and custodians are assigned. • Will create an automated compliance dashboard to facilitate monthly reporting to executive leadership. • Will prioritize high-risk Medicaid systems, targeting completion within three months and achieving full compliance with Texas Administrative Code (TAC) 202 requirements within twelve months. The Deputy Chief Information Officers (DCIO) and Chief Product Officers for System Applications, Public Health Applications, and Texas Integrated Eligibility Redesign System (TIERS)/Medicaid Enterprise Systems (MES) will provide support and assistance to the program areas in creating Plan of Actions and Milestones and completing risk assessments for all systems provided in the executive report for their respective areas related to the audit. Implementation date: February 28, 2027 Responsible persons: Anil Koindala, Chief Information Security Officer Leatha Marr, DCIO and Chief Product Officer, System Applications Madhavi Koganti, DCIO and Chief Product Officer, Public Health Applications James Huang, DCIO and Chief Product Officer, TIERS/MES
Corrective action plan: FDCM/OI has developed a comprehensive action plan to modernize and increase our detection of fraud in the child care program. Part of this modernization will include increased and more “real-time” monitoring of Board collection efforts. FDCM/OI is partnering with our Informat...
Corrective action plan: FDCM/OI has developed a comprehensive action plan to modernize and increase our detection of fraud in the child care program. Part of this modernization will include increased and more “real-time” monitoring of Board collection efforts. FDCM/OI is partnering with our Information, Innovation, and Insight Division (I3) to develop new dashboards and reports based upon weekly uploaded PIRTS data. This will allow FDCM/OI to generate weekly reports of Board collection letter non-compliance. If a Board fails to issue collection letters in a timely fashion, FDCM/OI will send a report to the Board Executive Director notifying them of non-compliance. Boards are also now required to have a Fraud Point of Contact (POC) that will be FDCM/OI’s direct liaison with the Board for all fraud matters. Additionally, FDCM/OI is conducting weekly PIRTS trainings throughout February for Boards. Boards have been asked to submit up to 5 fact finders who will be responsible for fraud case entry and management. The Board POC is ultimately responsible for every case. FDCM/OI is also reviewing our collection letters as a part of this process and generating prosecution referrals for cases which meet our criteria. It is our belief this will underscore the seriousness of the collection letters and increase their effectiveness. Finally, FDCM/OI will ensure that all relevant controlling documents, e.g. a new Workforce Development Letter, and all previous guidance is updated with this information. Implementation date: February 27, 2026 Responsible person: Jason Stalinsky, Division Director, Division of Fraud Deterrence and Compliance Monitoring.
Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC continues to be engaged in long-term planning related to improving FFATA reporting. Implementation date: September 1, 2027 Responsible person: Ari...
Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC continues to be engaged in long-term planning related to improving FFATA reporting. Implementation date: September 1, 2027 Responsible person: Ariana Torres, Deputy Director, Federal Funds
Corrective action plan: TANF/SEGIF: To ensure that correct UEIs are included on all Early Childhood Initiatives (ECI) contracts, the Early Childhood Initiatives (ECI) program has implemented a review system of the contracts and amendments prior to routing them through CAPPS FIN. The contract develop...
Corrective action plan: TANF/SEGIF: To ensure that correct UEIs are included on all Early Childhood Initiatives (ECI) contracts, the Early Childhood Initiatives (ECI) program has implemented a review system of the contracts and amendments prior to routing them through CAPPS FIN. The contract developer will create the document, and the assigned performance specialist will review the data included in the contract/amendment to ensure it is accurate before the contract is routed for approval. SUBG: Behavioral Health Services’ pass-through agreements effective September 1, 2026, will include 2 CFR §200.332 requirements. Implementation dates: TANF/SEGIF: September 1, 2025 SUBG: December 31, 2026 Responsible persons: TANF/SEGIF: Janene Roch, Manager, ECI Contracts and Finance SUBG: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security ...
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security Office for continuation of periodic reconciliation of HR data and network accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Work with Human Resources to establish a schedule of periodic reconciliation for HR data and case management application accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Review existing business process for offboarding separated employees and provided recommendations to HR for training and communication for staff. Recommendations to be provided by May 1, 2026. • Determine what technology solution may be needed by August 31, 2026, with consideration of effectiveness of mitigation actions, as noted above. Implementation dates: See Corrective action plan Responsible person: Angie Lindemann, Deputy Chief Information Officer
Corrective action plan: Program staff will ensure that a formal review by the Team Lead and the Manager of Fiscal and Reporting is completed prior to submission. The Team Lead will initiate the process by obtaining the obligation amount from the LIHEAP Contract Specialist and entering the amount int...
Corrective action plan: Program staff will ensure that a formal review by the Team Lead and the Manager of Fiscal and Reporting is completed prior to submission. The Team Lead will initiate the process by obtaining the obligation amount from the LIHEAP Contract Specialist and entering the amount into the quarterly report. The Manager of Fiscal and Reporting will review and confirm the amount to be submitted. Implementation date: April 30, 2026 Responsible persons: Michael De Young, Director of Community Affairs Cathy Jung, Senior Manager of Finance and Reporting
Corrective action plan: HHSC will conduct an end-to-end review of the sanctions process to identify and implement any needed changes to the business process, training, or system. Implementation date: May 31, 2026 Responsible person: Carrie Robertson, Manager, Strategy and Innovation–Business Integra...
Corrective action plan: HHSC will conduct an end-to-end review of the sanctions process to identify and implement any needed changes to the business process, training, or system. Implementation date: May 31, 2026 Responsible person: Carrie Robertson, Manager, Strategy and Innovation–Business Integration and Support
Corrective action plan: THECB ITS will: • Develop and implement a standardized process for all user access reviews, including a required template which documents review date, reviewer identity, scope, results, and remediation actions. • Maintain all documentation in a centralized location on our ITS...
Corrective action plan: THECB ITS will: • Develop and implement a standardized process for all user access reviews, including a required template which documents review date, reviewer identity, scope, results, and remediation actions. • Maintain all documentation in a centralized location on our ITS SharePoint site. • Implement regular monitoring to ensure reviews are performed time, and the proper documentation is retained. • We will seek to automate processes where possible. Implementation date: July 1, 2026 Responsible person: Layla Young, Brian Nolte, Joel Anguiano
Corrective action plan: TCEQ will provide targeted training to program staff on federal procurement requirements, including the necessity of coordinating all purchases through the Procurements & Contracts Section and completing required vendor compliance checks. Training will emphasize procedures fo...
Corrective action plan: TCEQ will provide targeted training to program staff on federal procurement requirements, including the necessity of coordinating all purchases through the Procurements & Contracts Section and completing required vendor compliance checks. Training will emphasize procedures for sole source or limited source procurements and reinforce staff responsibilities under 2 CFR procurement and internal control standards. Regular refresher sessions and documented guidance will help ensure consistent understanding and adherence to required procurement practices across all program areas. Implementation date: May 31, 2026 Responsible person: Yolanda Davis, Deputy Director, Financial Administration Division
Corrective action plan: ITS Management will establish a formal, documented user access review program applicable to both privileged and non-privileged network users. Key actions include: 1. Policy Updates: Revise information technology access control policies and procedures to re-quire periodic (at ...
Corrective action plan: ITS Management will establish a formal, documented user access review program applicable to both privileged and non-privileged network users. Key actions include: 1. Policy Updates: Revise information technology access control policies and procedures to re-quire periodic (at least annual) reviews of all network user access. 2. Standardized Process and Documentation: Implement a consistent, documented review process and maintain records in a centralized repository to ensure accountability and auditability. 3. Monitoring and Oversight: Implement oversight procedures to track completion of access re-views and remediation of identified issues, with reporting to IT and information security leadership to support governance. Implementation dates: 1. Policy and procedure updates: Expected completion by April 30, 2026 2. Standardized process and repository implementation: Expected completion by May 31, 2026 3. First completed annual review under the revised process: Expected completion by June 30, 2026 Responsible persons: Tara Mitchell, Director of IT Operations Sean Peterson, Chief Information Officer
Corrective action plan: A formalized process will be implemented, utilizing Standard Operating Procedures, to cover changes of hardware or software in relationship with network and infrastructure components. A change management tracking and approval system is under development that will be utilized ...
Corrective action plan: A formalized process will be implemented, utilizing Standard Operating Procedures, to cover changes of hardware or software in relationship with network and infrastructure components. A change management tracking and approval system is under development that will be utilized to track and provide audit logs of all network and infrastructure changes. Implementation date: August 31, 2026 Responsible person: Lars Hjaltman, CIO
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that ...
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that will aid in the process and will be implemented this year. • IT will document quarterly access reviews which are already done. • IT will work on enhancing automation and controls; Will utilize AI to assist. Implementation date: May 2026 Responsible person: Chris Bunton, CIO, Texas Department of Agriculture
Management Response: The University agrees with the finding. The identified issue was isolated and only impacted fall graduates. This issue was fully addressed when the university filed its fall 2025 enrollment reporting. The university has conducted an internal audit to identify students that were ...
Management Response: The University agrees with the finding. The identified issue was isolated and only impacted fall graduates. This issue was fully addressed when the university filed its fall 2025 enrollment reporting. The university has conducted an internal audit to identify students that were reported incorrectly and has manually updated files to ensure dates were properly reflected. At current state, internal monitoring and manual edits are made if discrepancies appear. The university has been in contact with PeopleSoft software related to the issue. Should the software issue not be resolved, the university plans to continue with manual edits to ensure proper reporting. Contact Person: Stacy Ramsey, University Registrar srramse@ilstu.edu Completion Date: December 2025
Information on the federal program: Subject: Special Education Cluster (IDEA) – Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal ...
Information on the federal program: Subject: Special Education Cluster (IDEA) – Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 22611-047-PN01, 22611-047-ARP, 22619-047-PN01, 22619-047-ARP Pass-Through Entity: Indiana Department of Education Compliance Requirement: Period of Performance Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Special Education Cluster program and Period of Performance compliance requirements. Context: During fiscal year 2023-24, the School Corporation was a member of Cooperative School Services (Cooperative). The Cooperative operated the special education programs and spent the federal money on behalf of its member schools. As the grant agreement was between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. For Special Education Cluster awards, funds must be obligated during the 27 months, extending from July 1 of the fiscal year for which the funds were appropriated through September 30 of the second following fiscal year. When testing transactions occurred in the liquidation period for the 22611-047-PN01, 22611-047-ARP, 22619-047-PN01 and 22619-047-ARP grant awards, two exceptions were identified in the sample of five transactions. For the above listed awards, costs must be obligated by September 30, 2023. For the two identified exceptions, an initial purchase order was made in September, but the ultimate transaction was paid to a separate vendor than the original purchase order, and this obligation was incurred in November 2023. This issue was isolated to fiscal year 2024. No costs incurred outside of the period of performance were identified in fiscal year 2025. Views of Responsible Officials and Corrective Action Plan: Management disagrees with part of the finding. The term “obligate” can be interpreted in various ways within our context. While we have a purchase order that was completed by September 30, we do agree that we changed vendors after September 30 and paid the non-public school directly. We agree with the finding that direct payment to a non-public school is not allowable. The purchase order is an internal written commitment to acquire the items/supplies, but it is not a binding written agreement to acquire “property” when we are purchasing supplies until it is provided to the vendor. The purchase order is authorization and approval to purchase the items/supplies. Once the purchase order is provided to the vendor, it is committed and is the binding written agreement. The invoice is an order to pay the obligation. Responsible Party and Timeline for Completion: Corrective action plan has been implemented as this finding impacted fiscal year 2024 but did not recur in fiscal year 2025. Sarah Claton, Cooperative School Services director, and Tracy Albertson, Director of Finance, will oversee the corrective action plan to monitor the cooperative on an ongoing basis.
The City will establish procedures whereby the Clerk and Manager will prepare the Schedule of Expenditures of Federal Awards (SEFA) at each fiscal year end.
The City will establish procedures whereby the Clerk and Manager will prepare the Schedule of Expenditures of Federal Awards (SEFA) at each fiscal year end.
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
Federation of Appalachian Housing Enterprises, Inc. acknowledges that we should have been filing information for all of our grantees over $30,000 on the FFATA Sub-award Reporting System website. We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the w...
Federation of Appalachian Housing Enterprises, Inc. acknowledges that we should have been filing information for all of our grantees over $30,000 on the FFATA Sub-award Reporting System website. We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the website, and we have included FFATA registration as a step in the creation of all future RDCA grantees.
Coronavirus State and Local Fiscal Recovery Funds Procurement, Suspension, and Debarment Planned Corrective Action: The City implemented a Vendor’s Doing Business Policy in FY 2025-26 requiring all new vendors be searched on SAM.gov and California Secretary of State prior to executing a contract, wi...
Coronavirus State and Local Fiscal Recovery Funds Procurement, Suspension, and Debarment Planned Corrective Action: The City implemented a Vendor’s Doing Business Policy in FY 2025-26 requiring all new vendors be searched on SAM.gov and California Secretary of State prior to executing a contract, with emphasis on federal awards. Anticipated Completion Date: March 9, 2026 Responsible Contact Person: Gretchen Hoskins, Finance Director
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