Corrective Action Plans

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Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CH...
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CHP will be updating internal controls to include evidence of appropriate reviews and approvals of rent reasonableness.
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project...
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Recommendation: During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their monthly processes to ensure that program income was disbursed prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure appropriate and timely application of program income. Corrective Action Planned: Inova Grants Accounting and Inova Juniper Program (IJP) directors will work collaboratively to disburse funds available from program income prior to requesting additional cash payments from RWHAP funds. Inova implemented a Program Income from Sponsored Programs policy in February 2025. Inova will assess this written procedure and revise as necessary to ensure that program income is applied before requesting federal reimbursement. Inova will review federal grant requirements related to program income and identify sources of program income during kickoff meetings for new awards. Mandatory training will be conducted for program and finance staff responsible for the administration of these awards. (2 CFR 200.307 and 200.305) Inova will require a monthly reconciliation of program income earned and expenditures by grant. Program income tracking will also be included in monthly grant variance reports. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
View Audit 372193 Questioned Costs: $1
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
Management should implement a procedure requiring authorization and approval from Chief Financial Officer, Chief Executive Officer or Chief Operating Officer for all nonrecurring purchases prior to initiation of the purchase.
Management should implement a procedure requiring authorization and approval from Chief Financial Officer, Chief Executive Officer or Chief Operating Officer for all nonrecurring purchases prior to initiation of the purchase.
View Audit 372187 Questioned Costs: $1
Finding Number: 2024-001 Finding Title: Late Issuance of 2024 Single Audit Report Package Identification of federal programs: All Assistance Listing Numbers included on the schedule of expenditures of federal awards for the year ended December 31, 2024. Cause: The delay was due to delays in obtainin...
Finding Number: 2024-001 Finding Title: Late Issuance of 2024 Single Audit Report Package Identification of federal programs: All Assistance Listing Numbers included on the schedule of expenditures of federal awards for the year ended December 31, 2024. Cause: The delay was due to delays in obtaining necessary documentation for audit completion. Effect: Late submission of the audit package constitutes noncompliance with federal requirements. Corrective Action Taken: Management will work to meet audit deadlines and assign responsibilities for timely submission. Responsible Party: Marta Carrigan, Executive Director Anticipated Completion Date: September 30, 2026
Contact Person Tamra Sperry, Auditor Corrective Action Plan The County will ensure records are reconciled and available for audit within a timely manner of year end. Planned Completion Date for CAP Ongoing
Contact Person Tamra Sperry, Auditor Corrective Action Plan The County will ensure records are reconciled and available for audit within a timely manner of year end. Planned Completion Date for CAP Ongoing
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Execu...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175 Questioned Costs: $1
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Direc...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Direc...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Direc...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Finding 1162353 (2024-002)
Material Weakness 2024
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Report...
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Reports are expected to be filed correctly and timely, with future education being sought as needed.
Finding 1162350 (2024-001)
Material Weakness 2024
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. ...
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. The Director reports several calendaring mechanisms are in place and the reports are being tracked by duplicative methods since that error.
In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action wi...
In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action with a Target Completion Date of December 31, 2025: The Town will draft and present a formal policy addressing this finding to the Board of Selectmen for review and approval prior to December 31, 2025. Responsible Party: Tammy Penny, Finance Director 6 Village Green Pelham, NH 03076 Phone: 603-508-3072 Email: TPenny@Pelhamweb.com Implementation of this policy will ensure that the Town is in compliance with applicable requirements and will prevent recurrence of the cited issue in future audits.
The Greening of Detroit has adjusted all indirect costs from being charged to the DNR grant for the current year 2025 and future years. The Greening of Detroit has also updated the grant budget to reflect the change to match the grant requirements.
The Greening of Detroit has adjusted all indirect costs from being charged to the DNR grant for the current year 2025 and future years. The Greening of Detroit has also updated the grant budget to reflect the change to match the grant requirements.
The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the ...
The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the clearing house.
Views of Responsible Officials and Planned Corrective Action: The Designees of the Grants Monitoring and Compliance team will oversee the completion of a physical inventory of all equipment that exceed $5,000 by October 31, 2026. The Grants team will also house documentation.
Views of Responsible Officials and Planned Corrective Action: The Designees of the Grants Monitoring and Compliance team will oversee the completion of a physical inventory of all equipment that exceed $5,000 by October 31, 2026. The Grants team will also house documentation.
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: • States and U.S. territories • Tribal governments that are allocated more than $30 million in SLFRF funding • Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C • Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding • NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.
November 4, 2025 Carver, Florek & James CPA’s Attn: Keegan Witt Audit Findings Corrective Action Plan Finding number: Section III: Federal Awards Findings and Questioned Costs Contact Person Responsible: Bonnie Buckingham Corrective Action Planned: Financial procedures that Community Food & Agricult...
November 4, 2025 Carver, Florek & James CPA’s Attn: Keegan Witt Audit Findings Corrective Action Plan Finding number: Section III: Federal Awards Findings and Questioned Costs Contact Person Responsible: Bonnie Buckingham Corrective Action Planned: Financial procedures that Community Food & Agriculture routinely follow are as follows: - Operations & Finance Manager will pull reports from QuickBooks accounting software for all federal grants for which a request for funds will be generated. - Executive Director reviews the draw down request, signs off on it, and the Executive Director or the Operations & Finance Manager files a request from the Federal portal, for funds expended for a specific program. All current and future expenditures and drawdown requests will be signed and dated with an electronic stamp certification prior to any drawdown request, as per the Financial Procedures stated above. All staff have been made aware of the strict adherence to this policy. Anticipated Completion Date will be immediate. Sincerely, Bonnie Buckingham Executive Director
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does th...
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does the payroll. We save a backup timecard report each payroll that we are paying from the approved by the employee's supervisor. We also have an internal worksheet that we use to document any changes that are made. Once the accountant is done with her review the controller will do the second review before we finish processing the payroll enforcing internal controls that are in place and being followed.
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will implement a monitoring system to insure timely review and filing of quarterly reports. Pers...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will implement a monitoring system to insure timely review and filing of quarterly reports. Person Responsible: BCCD Manager Anticipated Completion Date: 11/12/2025
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will review federal suspended and debarred listings prior to awarding any projects. Person Respo...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will review federal suspended and debarred listings prior to awarding any projects. Person Responsible: BCCD Manager Anticipated Completion Date: 11/12/2025
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: Bradford County will file reports on or before required due dates. Person Responsible: Michelle Shedden, chie...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: Bradford County will file reports on or before required due dates. Person Responsible: Michelle Shedden, chief Clerk Anticipated Completion Date: 11/12/2025
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