Corrective Action Plans

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Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automate...
Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automated procurement approval process that allows us to set approval levels for each user and will reduce potential for errant approvals Ensure all new management staff receive and acknowledge the procurement policy
COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify th...
COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify the federal nature of all awards and stay current on SEFA and Uniform Guidance
Finding 574051 (2024-001)
Significant Deficiency 2024
The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Direct...
The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Director and approved by the Finance Director prior to submission to the auditing firm. In addition to federal grants adopted as part of the City's annual operating budget, after adoption of the annual operating budget any federal grant approved by City Council for acceptance and expenditure will be maintained in the City's electronic archival system. The SEFA will be compard to the list of budgeted grants and the grants accepted after adoption of the annual operating budget to ensure grants are appropriately reported on SEFA.
Finding 574046 (2024-002)
Significant Deficiency 2024
When submitting SLFRF Project & Expenditure Report, the City will break out expenditures into more detailed groupings of closely related activities. Past reports were submitted as one project which falls under SLFRF 6-Revenue Replacement 6.1-Provisions of Government Services.
When submitting SLFRF Project & Expenditure Report, the City will break out expenditures into more detailed groupings of closely related activities. Past reports were submitted as one project which falls under SLFRF 6-Revenue Replacement 6.1-Provisions of Government Services.
2024-001: Internal Control Over Compliance with Subrecipient Monitoring and Noncompliance with Subrecipient Monitoring U.S. Department of Health and Human Services; Passed through the State of Tennessee Department of Health: ALN #93.558 Temporary Assistance for Needy Families Management’s Response: ...
2024-001: Internal Control Over Compliance with Subrecipient Monitoring and Noncompliance with Subrecipient Monitoring U.S. Department of Health and Human Services; Passed through the State of Tennessee Department of Health: ALN #93.558 Temporary Assistance for Needy Families Management’s Response: We concur. View of Responsible Officials and Corrective Action: United Way has an Agency Eligibility Review (AER) to ensure an organization is financially sound prior to awarding funding. As part of this process, subrecipients are required to provide their most recent From 990, as well as audited or reviewed financial statements, based on their gross revenue. United Way utilizes the AER as part of subrecipient application process government grants awarded to United Way. Historically, the majority of the government grants awarded to United Way have been for a 12-month period. However, the Temporary Assistance for Needy Families grant represents the first multi-year grant received by United Way from the State. Due to the multi-year nature of this award, United Way initially obtained financial records only after subrecipients entered the program. Going forward, we will review our processes to ensure financial records are collected and reviewed in a timely manner for all multi-year grants. The Senior Director of Innovation & Strategy and the Senior Director of Finance will obtain and review the most recent audited financial statements for the subrecipients. Supporting documentation will be maintained with the grant activity to ensure proper compliance documentation is kept. Name(s) of the Contact Person(s) Responsible for Corrective Action: Rod DeVore and Matt Lim Anticipated Completion Date: September 30, 2025
Finding 574028 (2024-003)
Significant Deficiency 2024
During our testing, we noted there was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approv...
During our testing, we noted there was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approval process for the drawing of federal funding. In addition, it is important to establish a clear process and timeline for performing draws. This may involve regular monitoring of expenditures, timely submission of draw requests, and efficient processing of those requests. By implementing an approval and a timely draw process, the organization can enhance internal controls, reduce the risk of fraud, and ensure the accuracy and integrity of the fund draw process, and can better manage its cash flow, meet its financial obligations, and maintain the smooth operation of the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement an electronic approval system, and draws will be completed within 30 days of month end. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: the planned corrective action will be completed by August 2025.
Finding 574022 (2024-004)
Significant Deficiency 2024
During our testing, we found that the Organization provided documentation showing that the vendors used in the federal program were not listed as suspended or debarred according to the Sam.gov website, in line with their internal control procedures. However, there was no documentation indicating tha...
During our testing, we found that the Organization provided documentation showing that the vendors used in the federal program were not listed as suspended or debarred according to the Sam.gov website, in line with their internal control procedures. However, there was no documentation indicating that the verification was performed prior to entering the transactions. Recommendation: The Organization should establish and enforce controls to verify that vendors are not suspended or debarred prior to entering any transactions and maintain this documentation. This measure ensures the integrity of the procurement process and mitigates risks associated with engaging disqualified vendors. In 2024, the threshold amount for suspension and debarment checks was $25,000. Transactions equal to or exceeding this amount required verification to confirm that the entity involved was not debarred or suspended. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement a process to screen vendors to ensure compliance with applicable regulations. Planned completion date for corrective action plan: the planned corrective action will be completed by August 2025. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance If the oversight agency has questions regarding this plan, please call Regine Metellus, Vice President of Finance at 215-575-0444 ext. 163.
Finding 574021 (2024-002)
Significant Deficiency 2024
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort ...
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by October 2025.
2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rent...
2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rented to eligible low-income households. Complete and accurate income documentation is essential to demonstrate compliance with program eligibility requirements and long-term affordability commitments. Condition: During our review of 34 tenant files for HOME-funded rental units, we noted the following: • 6 files did not contain any income verification documentation • 1 file include income documentation, but it was incomplete and missing required supporting documentation Cause: These issues primarily occurred during a transition in property management. The change in personnel and processes led to a lapse in documentation and inconsistent application of income verification procedures. Effect: Without proper income verification, there is a risk that units may be rented to households that do not meet eligibility requirements. Additionally, the absence of documentation may hinder the Organization’s ability to demonstrate compliance during monitoring or audit reviews. Questioned Costs: Not applicable. Auditor’s Recommendation: We recommend that management strengthen internal controls over the income verification process by: • Implementing a standardized checklist for required documentation • Providing staff training on income verification procedures • Conducting supervisory reviews of all files prior to tenant approval, especially during periods of staff transition Auditee’s Response: Management agrees with the finding and has taken steps to address the issue. Four of the seven identified files have been updated with complete income documentation for 2025, and the remaining three are in process. Contact Person: Brad Hinkfuss Anticipated Completion: 9.30.2025
Recommendation: We recommend that the Board of Education utilize the accounting system to reconcile cash, accounts receivable, accounts payable, deferred inflows of financial resources in addition to the income and expenditures for educational grants. In addition, we recommend moving the grant accou...
Recommendation: We recommend that the Board of Education utilize the accounting system to reconcile cash, accounts receivable, accounts payable, deferred inflows of financial resources in addition to the income and expenditures for educational grants. In addition, we recommend moving the grant accounting from the General Fund to a Special Revenue Fund where it is better classified. Management’s Response: Completed - As of July 1, 2023, the Board of Education separated Operating and Grant check runs to hit the respective bank accounts. This also includes the payroll account. Grant payroll totals are transferred to the payroll account from the Grant account.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD guidelines require Project cash to be maintained in financial institutions, which meet minimum GNMA ratings, when balances exceed federal insurance limits. Condition: The Organization maintains cash balances in excess of federally insured limits in a financial institution that does not meet HUD guidelines. Questioned costs: None Context: The cash balance as of December 31, 2024 was approximately $740,000, held in two financial institutions, which exceeded federal insurance limits by approximately $470,000. Cause: As the Organization is a community based non-profit organization, management considers supporting a local bank to be a worthwhile endeavor. Effect: No negative effect was discovered during the audit. Repeat Finding: No. Recommendation: The Organization should transfer all funds to a financial institution that meets HUD guidelines. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevins mission in the community. Given Nevins current financial struggles, the balance in the bank seldom exceeds the $250,000.00 threshold.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD requires the Organization to make mortgage payments on a timely basis. Condition: Mortgage payments for February, March, April and May 2024 were not received by the mortgage company promptly. Questioned costs: None Context: February, March, April and May 2024 mortgage payments were received by the mortgage company subsequent to the 15th of the following month, which is considered late per HUD guidelines. Cause: Mortgage payments were being funded with approved withdrawals from reserve accounts which delayed timing of payment. Effect: Late charges were assessed to the Project. Repeat Finding: No. Recommendation: Mortgage payments should be made by the due date. Action Taken: Nevins was in touch with HUD monthly and developed a repayment plan but could not follow through. Nevins engaged with Alliance Healthcare for Accounts Receivable assistance in the fall of 2024 and then entered into a Management agreement with Alliance Healthcare in June of 2025.
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should...
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures to admit applicants in order of wait list priority and document all applicants admitted and denied in accordance with HUD guidelines. Action Taken: REACH has policies in place to admit applicants in the order of their waitlist priority. Management works with on-site property staff and provides training on the prioritization of wait list applicants. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance with required regulations. Completion Date: June 30, 2025.
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should...
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that EIVs and recertifications are performed timely, inspections are completed, waitlists are being completed and followed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance. Completion Date: June 30, 2025.
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should immediately reimburse the amount due to the property and establish procedures to ensure payments of this nature are not made in the future. Action Taken: REACH has policies in place to ensure that costs are allocated to the appropriate property. In 2024, costs from an adjacent property, Community Housing I, were accidentally paid by Community Housing II. These funds were repaid to the Community Housing II in 2025. Completion Date: June 30, 2025
View Audit 364592 Questioned Costs: $1
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that move out inspections are performed timely, security deposits are returned timely and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Program. Action Taken: REACH has policies in place to ensure security deposits are returned in a timely manner. Staffing shortages at the property had an impact on the timely return of security deposits. As new staff are brought onboard training is provided and management will continue to coordinate and provide assistance to on-site staff to ensure that the security deposits are being returned or an itemized list of charges is provided and properties are in compliance. Completion Date: June 30, 2025.
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that EIVs are performed timely, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance. Completion Date: June 30, 2025.
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor c...
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to ensure that HQS inspections are done in a timely manner. Staffing shortages at the property had an impact on the completion of HQS inspections in 2024. As new staff are brought onboard training is provided and management will continue to coordinate and provide assistance to on-site staff to ensure that the inspections are being completed and properties are in compliance.
Federal Award Findings and Questioned Costs Item 2024-005 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...
Federal Award Findings and Questioned Costs Item 2024-005 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Action Taken: REACH has policies in place to ensure that move out inspections are done in a timely manner. Staffing shortages at the property had an impact on the timeliness of the move out. As new staff are brought onboard training is provided and training is provided to on-site staff to ensure that the inspections are being completed and properties are in compliance. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.
Federal Award Findings and Questioned Costs Item 2024-004 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...
Federal Award Findings and Questioned Costs Item 2024-004 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures to ensure the correct amount is being transferred into the replacement reserve account monthly. Action Taken: During 2024 when a rental increase was approved it came to management’s attention that the correct amount was not being deposited into the replacement reserve. Management had not received any previous notification from HUD that the deposits were insufficient and began payment of the agreed upon amount in September, 2024. The entity does not have the funds to adjust for payments prior to September, 2024.
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should change its po...
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulations. Action Taken: REACH has policies in place to ensure that the return of tenant security deposits are done in a timely manner. Staffing shortages at the property had an impact on the timeliness of the return of security deposits. As new staff are brought onboard training is provided and training is provided to on-site staff to ensure that the return of security deposits are being completed and properties are in compliance. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.
Response/Corrective Action Plan: We concur with the recommendation. We will work to implement policy and procedures over federal grants.
Response/Corrective Action Plan: We concur with the recommendation. We will work to implement policy and procedures over federal grants.
The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.
The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.
Recommendation: The auditee implement procedures to ensure the timely submission of future Single Audit reporting packages to the FAC. This may include establishing an internal deadline well in advance of the federal due date, assigning responsibility to a designated staff member, and monitoring su...
Recommendation: The auditee implement procedures to ensure the timely submission of future Single Audit reporting packages to the FAC. This may include establishing an internal deadline well in advance of the federal due date, assigning responsibility to a designated staff member, and monitoring submission status. Views of Responsible Officials: Management concurs with the finding and has implemented procedures to ensure future submissions to the FAC are made within the required timeframe.
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