Corrective Action Plans

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Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a sy...
Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. The Select Board will review this draft at their meeting in January 2024, edits will be made and then it will be sent to legal for final review before adoption. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: The processing of invoices for the warrant has been corrected as of December 2023. The Procurement Policy was approved and implemented by the Select Board on January 23, 204.
CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and is drafting a new Internal Controls Policy that will address this deficiency. The Select Board will review this draft at their meeting in February or March 2024, edits will be made and then it will be sent to legal for final review before adoption. This policy will include sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: It is anticipated that the Internal Controls Policies and Procedures will be approved and adopted by June 2024 by the Select Board. Implementation will be July 1, 2025 with the new chart of accounts.
CORRECTIVE ACTION PLAN (Concerning Finding 2022-003) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-003 The current Town Manager was appointed by...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-003) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the Treasurer and the Select Board. She has implemented a process of having the Treasurer complete a warrant each week. The Select Board meets bi-monthly and the Town Manager has the Select Board review and approve all warrants as a regular action item in their meeting. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: This corrective action has been implemented as of October 2023.
Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...
Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.
Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Per...
Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations
Item 2022.006 - Cash Manaaement Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures ...
Item 2022.006 - Cash Manaaement Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval process, submission to the funding agency, and the recording of the drawdown in the accounting system immediately after submission • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices
Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommenda...
Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommendation: The auditors recommended that ITCN implement the recommendations noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: This broad finding is being addressed by the corrective actions above. Fiscal contractors are providing quarterly compliance monitoring. ITCN’s Compliance Officer has initiated quarterly internal monitoring reviews. Migration to MIP/Microix will enhance reporting and compliance tracking. Training will ensure fiscal staff maintain compliance standards long-term. Anticipated Completion Date: The additional monitoring began in June 2024, with integration and staff training to be fully complete by June 2026.
Finding 1175571 (2022-009)
Material Weakness 2022
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
Finding 1175570 (2022-008)
Material Weakness 2022
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.
Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors...
Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors. Procurement procedures will be updated to clearly define vendor classification and SAM.gov requirements. Anticipated Completion Date: March 2026.
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.
Finding 2022-015 Allowable Costs and Activities Individual(s) Responsible: Tribal Council; Michelle Thomas, Acting Executive Director; Tyce Martin, HR Generalist; Program Directors; and Enterprise Managers. Action: The current Tribal Council will ensure that all required documentation is maintained ...
Finding 2022-015 Allowable Costs and Activities Individual(s) Responsible: Tribal Council; Michelle Thomas, Acting Executive Director; Tyce Martin, HR Generalist; Program Directors; and Enterprise Managers. Action: The current Tribal Council will ensure that all required documentation is maintained as supporting backup for all purchase requisitions, including proper signatures, prior authorization, and related approvals. In addition, all employees will have appropriate Personnel Action Notices (PANs) on file, and all timesheets will be properly completed and signed by both the employee and their supervisor. Anticipated Completion Date: March 2026.
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.
Finding 2022-012 Matching, Level of Effort and Earmarking Individual(s) Responsible: Cheryl DuBois, Head Start Director and Paula Vann, Grants Compliance Officer. Action: Make sure all reporting requirements are met. Maintain enrollment documentation and provide information upon request. Anticipated...
Finding 2022-012 Matching, Level of Effort and Earmarking Individual(s) Responsible: Cheryl DuBois, Head Start Director and Paula Vann, Grants Compliance Officer. Action: Make sure all reporting requirements are met. Maintain enrollment documentation and provide information upon request. Anticipated Completion Date: March 2026.
Finding 2022-011 Fixed Asset Inventory Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Michelle Thomas, Acting Executive Director; Program Directors; Enterprise Managers; and Rona Johnson-Murillo, Accounting Director. Action: Compile inventory listing by July 1st of each fiscal year. An...
Finding 2022-011 Fixed Asset Inventory Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Michelle Thomas, Acting Executive Director; Program Directors; Enterprise Managers; and Rona Johnson-Murillo, Accounting Director. Action: Compile inventory listing by July 1st of each fiscal year. Anticipated Completion Date: March 2026.
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to documen...
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to document that it had been approved by management to pay. During this period of 2022 we were on a manual accounts payable system. Invoices were approved before payment was made by email and the email was to be printed and attached. In September of 2022 we implemented a new ERP system. This system requires electronic approval by management for the invoice to be paid. Ferrick Jones, Controller, is responsible for ensuring this is remediated.
2022-003—EQUIPMENT MANAGEMENT (EQUIPMENT IDENTIFICATION/TAGGING) Response: Management concurs with the finding. Corrective Action Plan: Management will update written property and equipment procedures to require tagging of all federally funded equipment upon receipt. The Innovation Program Manager w...
2022-003—EQUIPMENT MANAGEMENT (EQUIPMENT IDENTIFICATION/TAGGING) Response: Management concurs with the finding. Corrective Action Plan: Management will update written property and equipment procedures to require tagging of all federally funded equipment upon receipt. The Innovation Program Manager will be responsible for tagging equipment, maintaining property records, and performing at least annual inventory and tagging reviews. All existing federally funded equipment currently in use, including the TVAC machine, will be reviewed and appropriately tagged. Designation of Employee Position Responsible for Meeting Deadline: Innovation Program Manager — by January 31, 2023.
Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control ...
Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control policies to document verification of vendors who may be listed in SAM for suspension and debarment. The College approved an updated procurement policy effective November 7, 2020, to adhere to Uniform Guidance. The College will strengthen (include) the suspension and debarment section to include a policy specific to Debarment and Suspension. Name of the contact person responsible for corrective action: Reatha Tom, Accounts Payable Specialist, and Clarissa Salhus, Finance Manager Planned completion date for corrective action plan: December 31, 2024
Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be es...
Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be established between Grant PI's and the Accounts Payable department to ensure that subrecipient payments are submitted and paid timely. These workflows will be included in the Accounts Payable procedures. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the cha...
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the challenge of hiring a Payroll Specialist. In September 2022, the College outsourced “Payroll” to Paycom. We continue to develop and communicate the unique needs of our College Payroll structure and Federal and private funding sources with Paycom and the College Human Resources to ensure that employees are paid properly. As such, the Business Office is undergoing a restructure and we have identified an internal candidate to take the lead on Payroll. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Reatha Tom, Accounts Payable Specialist, Michelle Ferron-Guppy, Director – Human Resources, and Zoy Zamudio-Lane, Human Resources Generalist Planned completion date for corrective action plan: September 30, 2024
Recommendation: We recommend the college retain evidence of the review of student accounts prior to disbursement of HEERF funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: No longer disbursing student HEERF fu...
Recommendation: We recommend the college retain evidence of the review of student accounts prior to disbursement of HEERF funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: No longer disbursing student HEERF funds. Discussions have taken place between Financial Aid department and Accounting staff requesting that supporting documentation is retained to show evidence that the College reviewed student accounts and eligibility prior to student disbursements. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
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