Corrective Action Plans

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Finding 406035 (2020-002)
Significant Deficiency 2020
Finding No. 2020-002 - Reporting Condition Our audit procedures revealed instances where reports required to be filed under the grant agreement were either not filed at all or filed after the due date. The Hospital did not provide evidence of the June and July 2020 submission. Also, the expenses rep...
Finding No. 2020-002 - Reporting Condition Our audit procedures revealed instances where reports required to be filed under the grant agreement were either not filed at all or filed after the due date. The Hospital did not provide evidence of the June and July 2020 submission. Also, the expenses reports related to November and December 2020 were submitted on December 30, 2020 (15 days later) and February 5, 2021 (21 days later). Hospital’s Response The Hospital agrees with this finding. Corrective Action Plan On March 2, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date March 2, 2022
Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding No Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Dra...
Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding No 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
Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding No Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Dra...
Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding No 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
2020-108 Lack of Controls over Costs Submitted for Reimbursement Condition: The Organization included an invoice for reimbursement under the program for which a vendor credit memo for the full amount of the invoice had been received due to miscoding of the credit memo to the correct COVID-19 class ...
2020-108 Lack of Controls over Costs Submitted for Reimbursement Condition: The Organization included an invoice for reimbursement under the program for which a vendor credit memo for the full amount of the invoice had been received due to miscoding of the credit memo to the correct COVID-19 class on the general ledger. In addition, the Organization did not include an applicable invoice for COVID-19 expenses for reimbursement due to the same miscoding of the COVID-19 class to the general ledger. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. Management understands the importance of reviewing the posting of credit memos or applicable invoices to ensure they are posted correctly. We will update our policy to include a process for review of credit memos prior to posting. The planned corrective action for this finding is currently in the process of development, approval, and implementation. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
2020-107 Lack of ACH Payment Review and Approval Condition: Payments are not reviewed prior to ACH payments. The Organization has no documented policies and procedures for handling the processing and review of ACH payments. Corrective Action Planned: : The Organization has hired a new Chief Finan...
2020-107 Lack of ACH Payment Review and Approval Condition: Payments are not reviewed prior to ACH payments. The Organization has no documented policies and procedures for handling the processing and review of ACH payments. Corrective Action Planned: : The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. Management understands the importance of reviewing the posting of credit memos or applicable invoices to ensure they are posted correctly. We will update our policy to include a process for review of credit memos prior to posting. The planned corrective action for this finding is currently in the process of development, approval, and implementation. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
2020-106 Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The ...
2020-106 Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: Implemented
2020-105 Lack of Required Policies Associated with Procurement Condition: The Organization does not have written policies in regards to procurement to ensure federal awards are being spent in accordance with federal and other specific requirements under the award. Corrective Action Planned: The Or...
2020-105 Lack of Required Policies Associated with Procurement Condition: The Organization does not have written policies in regards to procurement to ensure federal awards are being spent in accordance with federal and other specific requirements under the award. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization will review and update its existing policies to include procurement to ensure federal awards are being spent in accordance with federal and other specific requirements under the awards. The Organization expects to have this implemented by March 1, 2023. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
2020-104 Lack of Documentation Related to Reporting and Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation in support of reporting requirements and there was no review of the reports prior to submission to the grantor, other than the review...
2020-104 Lack of Documentation Related to Reporting and Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation in support of reporting requirements and there was no review of the reports prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its reporting policy and implemented the changes. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: Implemented
2020-102 Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization...
2020-102 Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: Implemented
2020-101 Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale ...
2020-101 Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by March 1, 2023. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion. Person Responsible for Corrective Action: Robert Thompson, Chief Operating Officer Anticipated Completion Date: March 1, 2023
Corrective Action Plan: The Program has designed and implemented policies and procedures that enable the Compliance division to use the risk assessment results as a work plan for performing the site visits and monitoring of subrecipients on an annual basis. COR3 will continue to follow its policy fo...
Corrective Action Plan: The Program has designed and implemented policies and procedures that enable the Compliance division to use the risk assessment results as a work plan for performing the site visits and monitoring of subrecipients on an annual basis. COR3 will continue to follow its policy for the management and monitoring of its subrecipients to ensure their compliance in managing federal funds. Contact Person: Alejandro Nieto, Compliance Director Anticipated Completion Date: No later than December 31, 2023
Finding: 2020-004 - Reporting Significant Deficiency in Internal Controls Over Compliance and Instance of Noncompliance Recommendation: The Organization should implement controls to ensure all reporting, both financial and performance, is completed, reviewed, and submitted before the specific repor...
Finding: 2020-004 - Reporting Significant Deficiency in Internal Controls Over Compliance and Instance of Noncompliance Recommendation: The Organization should implement controls to ensure all reporting, both financial and performance, is completed, reviewed, and submitted before the specific report deadlines. Corrective Action Plan: In working with HighPoint CPA, the WWBC has implemented the online accounting system DEXT: all invoices, receipts, bank statements and deposits are loaded in the program and the Executive Director is responsible for categorizing the data, ensuring proper fiscal grant management and is reviewed by the HighPoint CPA team and is reconciled with QuickBooks. The finance committee which meets the 2nd Tuesday of every month reviews the past months financials to ensure compliance. Paper copies are also printed out and filed. Anticipated Completion: January 2021 Responsible Party: Board of Directors and Executive Director
Finding: 2020-003 - Period of Performance Significant Deficiency in Internal Controls Over Compliance and Instances of Noncompliance Recommendation: The Organization should implement controls to ensure all expenditures allocated to grants are for costs incurred during the specified period of perfor...
Finding: 2020-003 - Period of Performance Significant Deficiency in Internal Controls Over Compliance and Instances of Noncompliance Recommendation: The Organization should implement controls to ensure all expenditures allocated to grants are for costs incurred during the specified period of performance. Corrective Action Plan: In January 2021 the WWBC engaged with HighPoint CPA, a non-profit fiscal management firm that processes our accounting, payroll and/or tax needs. HighPoint CPA has implemented a new fiscal management system DEXT, that increases our grant management efficiency and tracking. The Executive Director meets the Monday before the monthly board meeting with the Board Chair and Treasurer to review financial statements and grant reporting documents in order to verify that they are free from material misstatement. In addition, the Finance and Audit committee meets the 2nd Tuesday of every month to ensure compliance. Anticipated Completion: January 2021 Responsible Party: Board of Directors and Executive Director
View Audit 9815 Questioned Costs: $1
Finding: 2020-002 - Allowable Costs & Period of Performance Material Weakness in Internal Controls Over Compliance and Instances of Noncompliance Recommendation: The Organization should implement controls to ensure accurate recordkeeping and document retention to substantiate expenditures allocate...
Finding: 2020-002 - Allowable Costs & Period of Performance Material Weakness in Internal Controls Over Compliance and Instances of Noncompliance Recommendation: The Organization should implement controls to ensure accurate recordkeeping and document retention to substantiate expenditures allocated to grants. Corrective Action Plan: In working with HighPoint CPA, the WWBC has implemented the online accounting system DEXT: all invoices, receipts, bank statements and deposits are loaded in the program and the Executive Director is responsible for categorizing the data, ensuring proper fiscal grant management and is reviewed by the HighPoint CPA team and is reconciled with QuickBooks. The finance committee, which meets the 2nd Tuesday of every month reviews the past month’s financials to ensure compliance. Paper copies are also printed out and filed. Anticipated Completion: January 2021 Responsible Party: Executive Director
View Audit 9815 Questioned Costs: $1
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to include procurement, suspension and debarment procedures and implemented a procedure for ensuring compliance with obtaining required bids, etc. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to include procurement and implemented a procedure for ensuring compliance with obtaining required bids, etc. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022
View Audit 7080 Questioned Costs: $1
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2023, we implemented additional procedures to more efficiently review drawdowns and supporting documentation. We updated our fiscal policies and procedures in 2023 to document a standar...
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2023, we implemented additional procedures to more efficiently review drawdowns and supporting documentation. We updated our fiscal policies and procedures in 2023 to document a standardized process for review and approval of drawdowns before request for reimbursement by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022
View Audit 7080 Questioned Costs: $1
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented additional procedures to more efficiently review payroll and supporting documentation. We updated our fiscal policies and procedures in 2022 to document a standardi...
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented additional procedures to more efficiently review payroll and supporting documentation. We updated our fiscal policies and procedures in 2022 to document a standardized process for review of payroll. Payroll cannot be processed without adequate review and documentation. Payroll is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal polic...
We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022
View Audit 7080 Questioned Costs: $1
We will ensure all required federal reports have a documented, formal review of the reports before they are submitted to ensure the information submitted is accurate.
We will ensure all required federal reports have a documented, formal review of the reports before they are submitted to ensure the information submitted is accurate.
We will perform the following to ensure only allowable costs are charged to the program: • Ensure all supporting vouchers are prepared and approved by different people • Ensure all supporting vouchers have the appropriate documentation including the invoice from each vendor and the underlying sup...
We will perform the following to ensure only allowable costs are charged to the program: • Ensure all supporting vouchers are prepared and approved by different people • Ensure all supporting vouchers have the appropriate documentation including the invoice from each vendor and the underlying support for what the gift card purchases were ultimately used to fulfill the grant purpose.
View Audit 3568 Questioned Costs: $1
Management concurs with the audit finding.
Management concurs with the audit finding.
Finding 2019‐001 Federal Agency: United States Department of Housing and Urban Development (HUD) Planned Corrective Actions: Responsible Official – Darryl Johnson, Deputy CFO Anticipated completion date – October 2025 Management will review its controls and update standard work documentation to ensu...
Finding 2019‐001 Federal Agency: United States Department of Housing and Urban Development (HUD) Planned Corrective Actions: Responsible Official – Darryl Johnson, Deputy CFO Anticipated completion date – October 2025 Management will review its controls and update standard work documentation to ensure that all loans and expenditures related to the Housing Trust Fund are appropriately accumulated and reported in the schedule of expenditures of federal awards (SEFA) for the period covered by the New York State Housing Finance Agency’s financial statements in accordance with Uniform Guidance 2 CFR section 200.502. All staff working on SEFA preparation and review, will receive additional education in reporting for federal programs.
In September 2021, the Authority hired fixed assets manager and two staffs who are responsible for monitoring the fixed assets. The fixed assets team will conduct fixed assets physical count before the end of fiscal year 2024. The result of the physical count will be reconciled to the fixed asset re...
In September 2021, the Authority hired fixed assets manager and two staffs who are responsible for monitoring the fixed assets. The fixed assets team will conduct fixed assets physical count before the end of fiscal year 2024. The result of the physical count will be reconciled to the fixed asset records. Also, a new fixed asset module is set to be implemented in the Fiscal Year 2025.
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