Corrective Action Plans

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Responsible Official’s Response and Corrective Action Planned: We have reached out to FEMA and was provided this summarized response: “The project was obligated as a small project. FEMA does not adjust the funding amount unless specific conditions are met. If the applicant was stating that the actua...
Responsible Official’s Response and Corrective Action Planned: We have reached out to FEMA and was provided this summarized response: “The project was obligated as a small project. FEMA does not adjust the funding amount unless specific conditions are met. If the applicant was stating that the actual cost for the small project was more than FEMA obligated, we would have to request what is called a New Small Project Overrun Appeal Request. But in this case, the actual cost resulted in an underrun based on the small project obligated amount. FEMA only asks for the applicants to apply the underrun amount back into the community." Management has also implemented a process to include financial oversight and review of all documents prior to submission to FEMA for reimbursement going forward. We will meet with all leadership staff to discuss documentation requirements necessary for FEMA reimbursements. Lastly, Management will only sign off on reimbursed costs after all changes to FEMA requests have been adequately documented.
View Audit 365308 Questioned Costs: $1
COVID-19-Coronavirus State and Local Relief Funds (CSLRF)-Assistance Listing No. 21.027 Allowable Activities/Costs Recommendation: The Town should review and enhance controls and procedures where necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...
COVID-19-Coronavirus State and Local Relief Funds (CSLRF)-Assistance Listing No. 21.027 Allowable Activities/Costs Recommendation: The Town should review and enhance controls and procedures where necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will continue to review and enhance controls where necessary to ensure that all State and Local Fiscal Recovery Funds (SLFRF) expenditures support an eligible COVID-19 public health or economic response. Name(s) of the contact person(s) responsible for corrective action: Tyler Home, Director of Finance Planned completion date for corrective action plan: 07/01/2024
View Audit 365251 Questioned Costs: $1
Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allow...
Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.
• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review firs...
• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review first three months of FY26 by 12/31/25
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Since notification of the recommendation WBC has verified the Suspension and Debarment status for each of the eight Vendors identified. None of the vendors identi...
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Since notification of the recommendation WBC has verified the Suspension and Debarment status for each of the eight Vendors identified. None of the vendors identified have been suspended or debarred or otherwise excluded from participating in the transaction. WBC has hired an Operations Manager. The Operations Manager is responsible for oversight and management of the WBC Procurement Policy in coordination with Finance. This includes ensuring Suspension and Debarment Status is verified as required by the policy. Weekly procurement staff meetings will be held to discuss and review current procurement transactions and issues. WBC will also hold an all-staff meeting focusing on the procurement policy and the responsibilities of all staff in compliance with the policy. Name(s) of the contact person(s) responsible for corrective action: Peter Stanton Planned completion date for corrective action plan: August 4, 2025. If the U.S. Department of the Interior - BOR has questions regarding this plan, please call Peter Stanton at 775-463-9887, Ext 101.
Finding 573666 (2024-003)
Significant Deficiency 2024
Action taken in response to finding: Trilogy will revise our monthly invoicing procedures to include a standardized step for verifying the indirect cost calculation. This will include recalculation of the indirect cost rate using actual monthly expenditures reflected in the grant invoices submitted...
Action taken in response to finding: Trilogy will revise our monthly invoicing procedures to include a standardized step for verifying the indirect cost calculation. This will include recalculation of the indirect cost rate using actual monthly expenditures reflected in the grant invoices submitted for reimbursement. This recalculation will ensure that indirect costs are proportionate and accurately reflect the approved rate and allowable base. Relevant staff members will receive training on proper indirect cost calculation methods, and how to apply the rate to the correct base and reconcile with monthly expenditures. We will implement a quarterly review of indirect cost charges to ensure continued accuracy and compliance. Any discrepancies will be addressed promptly and adjusted as needed. Name(s) of the contact person(s) responsible for corrective action: Shunita Rhodes & Hagar Buster Planned completion date for corrective action plan: July 2025
View Audit 364306 Questioned Costs: $1
Finding 573665 (2024-002)
Material Weakness 2024
Action taken in response to finding: Trilogy will conduct a thorough review of our current cost allocation procedures to identify gaps related to the timing and eligibility of expenses. Based on this review, we will revise our process to ensure that only allowable costs incurred within the grant’s p...
Action taken in response to finding: Trilogy will conduct a thorough review of our current cost allocation procedures to identify gaps related to the timing and eligibility of expenses. Based on this review, we will revise our process to ensure that only allowable costs incurred within the grant’s period of performance are charged. A multi-tiered review process will be established, to verify expense timing and relevance and to confirm compliance with grant terms. Staff will review descriptions and flag transactions that fall outside the grant’s period of performance. These controls will prevent such costs from being allocated unless properly justified and approved. Staff involved in grant management will receive updated training on federal cost principles, including the importance of period-of-performance compliance. Written guidance will be distributed to reinforce expectations. Name(s) of the contact person(s) responsible for corrective action: Shunita Rhodes & Hagar Buster Planned completion date for corrective action plan: July 2025
View Audit 364306 Questioned Costs: $1
2024-005 Lack of Written Allocation Plan for Shared Costs Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A plan has been written for FY25.
2024-005 Lack of Written Allocation Plan for Shared Costs Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A plan has been written for FY25.
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditure...
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.
View Audit 363843 Questioned Costs: $1
2024-002 Unnecessary spending of federal awards Federal Agency: U.S. Department of Treasury Pass Through Entity: Child Care Aware of Kansas Program Name: Coronavirus State and Local Recovery Funds (COVID-19) Assistance Listing Number: 21.027 Award Period: March 12, 2020 to June 30, 2023 Recommen...
2024-002 Unnecessary spending of federal awards Federal Agency: U.S. Department of Treasury Pass Through Entity: Child Care Aware of Kansas Program Name: Coronavirus State and Local Recovery Funds (COVID-19) Assistance Listing Number: 21.027 Award Period: March 12, 2020 to June 30, 2023 Recommendation: Policies and Procedures should be implemented for expenditures related to significant long-term commitments to undergo proper vetting to ensure the expense necessary prior to purchase. Action Taken (Unadutied): Management intends to enhance controls over the procurement process to require approval by Board of Directors for all purchase commitments exceeding a defined threshold. Contact Name – Ozel Soykan, Director of Finance Expected completion date – 12/31/2025 If the U.S. Department of Treasury has questions regarding this plan, please call Ozel Soykan at 785-423-2098.
View Audit 363590 Questioned Costs: $1
Recommendation: We recommend that the Parish enhance and document internal controls over financial reporting, as described in our recommendations described under item 2024-001, to prevent noncompliance of the Uniform Guidance as required. Corrective Action: The Parish has written a Standard Operati...
Recommendation: We recommend that the Parish enhance and document internal controls over financial reporting, as described in our recommendations described under item 2024-001, to prevent noncompliance of the Uniform Guidance as required. Corrective Action: The Parish has written a Standard Operating Procedure for “Grant Management - Financial Reporting & Reconciliation” which outlines the role of the Finance Department in monitoring grant activities including measures to ensure correct general ledger coding for budget planning, complete and accurate recording of grant expenditures and revenues, and administrative review to confirm reconciliation of grant activities against the general ledger on a monthly basis. This corrective action was approved and implemented effective 6/30/2025
Corrective Action Plan Year Ended December 31, 2024 Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2024-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Depa...
Corrective Action Plan Year Ended December 31, 2024 Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2024-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project #2365 – Award Year 2024 (Application 696220) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. Beginning in December 2024, as a commitment to strengthen our processes and ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible, management put a process in place to enhance procedures and controls for timesheets going forward to ensure full compliance with the Uniform Guidance requirements. This process was successfully implemented as of this date and for prospective periods. However, this process does not remedy the issue noted in the finding which relates to time worked from 2020-2022, which is before the process was in place. Therefore, the finding is repeated from the prior year. Anticipated Completion Date: Completed
Correction action • Finance will work HR and Program staff to document written procedures for staffing allocations. • Finance will strengthen monthly project monitoring of project activity and also ensure that budget changes, if necessary, are approved by the Grants Manager. • Drawdown process is be...
Correction action • Finance will work HR and Program staff to document written procedures for staffing allocations. • Finance will strengthen monthly project monitoring of project activity and also ensure that budget changes, if necessary, are approved by the Grants Manager. • Drawdown process is being revised to ensure that the general ledger activity, pending draw request, and vendor payables are all in sync. • Finance will contact Grant Manager responsible for each grant to develop plan of action for returning any overdrawn funds. Responsible Person • Associate Director - Finance Anticipated completion date • September 30, 2025
View Audit 362661 Questioned Costs: $1
In response to the Auditor’s recommendations and as corrective action, the responsible staff or department will locate, and document all required reports that were filed in accordance with the grant agreement requirements, including reconciliations with the Municipality’s official accounting subsidi...
In response to the Auditor’s recommendations and as corrective action, the responsible staff or department will locate, and document all required reports that were filed in accordance with the grant agreement requirements, including reconciliations with the Municipality’s official accounting subsidiary ledgers. Furthermore, the Municipality will design, document, establish, and provide the necessary training, along with written guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds.
Following the Auditor's recommendations and as corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including reconciliation thereof with the official Municipality’s accounting subsidiaries...
Following the Auditor's recommendations and as corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds.
The Municipality will designate the appropriate personnel to systematically identify, compile, and securely retain all required reports as stipulated in the grant agreement, ensuring reconciliation with the official accounting records and subsidiary ledgers. Furthermore, the Municipality will develo...
The Municipality will designate the appropriate personnel to systematically identify, compile, and securely retain all required reports as stipulated in the grant agreement, ensuring reconciliation with the official accounting records and subsidiary ledgers. Furthermore, the Municipality will develop and implement a comprehensive training program, accompanied by detailed written guidelines and procedures, to equip all staff involved in managing federal funds with the necessary knowledge and tools to maintain compliance and enhance accountability.
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditu...
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditures charged to grant programs. To address this finding, Tuerk House is taking the following corrective actions: ·Implementing a formal time and effort certification process that requires employees to certify actual time worked on federal grant activities on a regular basis, rather than relying on budgeted allocations. ·Developing a standardized cost allocation methodology that aligns with actual grant activity and is supported by verifiable documentation. ·Requiring that all expenditures charged to federal awards be supported by complete and accurate source documentation, including vendor invoices, timesheets, and approvals. ·Establishing a document retention policy consistent with 2 CFR § 200.334 to ensure all supporting records are retained for the required period and readily accessible for audit or review. Training sessions for program and finance staff will be conducted to ensure consistent understanding and application of these updated policies and procedures. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
View Audit 361681 Questioned Costs: $1
Finding 570574 (2024-003)
Significant Deficiency 2024
YWCA Madison, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, Wisconsin 53713 Audit period: January 1, 2024 – December 31, 2024 The findi...
YWCA Madison, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, Wisconsin 53713 Audit period: January 1, 2024 – December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINANCIAL STATEMENT FINDINGS SIGNIFICANT DEFICIENCY 2024-001 Recommendation: Management should implement procedures to ensure continuity of key financial controls during periods of personnel transition. This includes assigning interim reviewers, establishing clear handover protocols, and enforcing timely documentation of reviews to maintain financial oversight. Action Taken: Under the leadership of our new fractional CFO and outsourced accounting firm, we have implemented an accounting close and financial reporting management system using ClickUp. Each task impacting key financial controls now has both a designated preparer and reviewer. The system automatically tracks and displays the completion status of each control. Further review of financial schedules is documented through Google Drive approvals. Transitioning from manual to system-driven documentation ensures that, during staffing changes, task reassignments are more visible to all responsible team members. It is important to note that, due to capacity constraints during the transition, immediate reassignment of responsibilities was not feasible. However, once new team members were onboarded, a cumulative review of the period was conducted to ensure the completeness and accuracy of the financial information—ultimately reflected in an unmodified financial audit opinion. MATERIAL WEAKNESS 2024-002 Recommendation: Assign clear responsibility for maintaining and reviewing the monitoring checklist. Management should establish a recurring schedule (e.g., monthly or quarterly) for checklist reviews and ensure the results are documented and retained for accountability and audit purposes. Action Taken: The new fractional CFO, Grants & Compliance Director, and CEO have revised the monitoring checklist to separate financial and compliance controls, as these operate on different schedules. Financial controls have been integrated into the financial management project system in ClickUp. Compliance controls will be maintained within the grant management system and embedded into the grant management and reporting processes. FEDERAL AWARD FINDINGS DEPARTMENT OF TRANSPORTATION STATE OF WISCONSIN DEPARTMENT OF TRANSPORTATION 2024-003 Formula Grants for Rural Areas and Tribal Transit Program — Assistance Listing No. 20.509 Recommendation: Management should conduct a review of depreciation charges for the current and future years to ensure that federally funded assets are excluded from depreciation allocations to federal programs. Action Taken: We have added a new depreciation expense account to distinguish between allowable and non-allowable depreciation expenses in grant expenditure allocations. If there are questions regarding this plan, please call Tania Ibarra, CPA, at 608.347.6747. Sincerely, Geraldine Paredes Vásquez CEO gpvasquez@ywcamadison.org
View Audit 361592 Questioned Costs: $1
Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Explanation of disa...
Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create list of grants with pertinent contract terms for monitoring and reference. Highlight grants with term end dates within the fiscal year. 2. Update Grant Tracking workpapers to alert on grant year end and create allocation tab to separate payroll expenses that crossover grant end terms. Review non-payroll expenses to ensure they belong to proper grant term. 3. Monitor progress and review grants at fiscal year end to ensure process was followed. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: 8/31/2025
View Audit 361495 Questioned Costs: $1
Management concurs with the recommendation to implement internal controls to ensure all costs charged to the program are accurate, allowable, and properly allocated in accordance with the terms of the federal award, and that there is proper review and approval.
Management concurs with the recommendation to implement internal controls to ensure all costs charged to the program are accurate, allowable, and properly allocated in accordance with the terms of the federal award, and that there is proper review and approval.
View Audit 361435 Questioned Costs: $1
Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant managem...
Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant management procedures have been revised to verify that services are received and costs incurred within the authorized period of performance in accordance with 2 CFR § 200.403 before the costs are charged to a federal award. Staff involved in grant management will receive targeted training on 2 CFR requirements related to period-of-performance compliance and allowable cost timing. Anticipated Completion Date: September 30, 2025
View Audit 361417 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Unif...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Uniform Guidance.
View Audit 361368 Questioned Costs: $1
agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to subm...
agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to submitting reimbursement requests.
View Audit 361368 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance wi...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance with regard to the period of performance requirements.
View Audit 361368 Questioned Costs: $1
Finding 570037 (2024-005)
Material Weakness 2024
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as peri...
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as periodic internal audits to ensure compliance with the documentation requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All purchase-related supporting documentation will be transitioned to paper files to eliminate confusion created by the electronic record-keeping system, and to ensure that all staff requiring access to such documentation can immediately and easily retrieve them. Records will be maintained in the Finance Department office for seven years. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 06/12/2025
View Audit 361326 Questioned Costs: $1
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