Corrective Action Plans

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The Organization is aware of the error. The $11,451 was disbursed immediately subsequent to year end. The Organization has hired an additional accountant which will help with timeliness of payments.
The Organization is aware of the error. The $11,451 was disbursed immediately subsequent to year end. The Organization has hired an additional accountant which will help with timeliness of payments.
Recommendation: Vermont Youth Conservation Corps, Inc. should put procedures In place to ensure that they are in compliance with grant agreements and that all required matching dollars are satisfied in the respective award period. ...
Recommendation: Vermont Youth Conservation Corps, Inc. should put procedures In place to ensure that they are in compliance with grant agreements and that all required matching dollars are satisfied in the respective award period. Action Taken: Vermont Youth Conservation Corps, Inc. has implemented procedures to ensure grant matching requirements are satisfied at the time of final report submission. If Corporation for National and Community Service (CNCS) has any questions regarding this plan, please call Hapy Mayer at (802) 434-3969 ext. 134.
View Audit 364046 Questioned Costs: $1
Corrective action planned: Two new policies will be implemented; a board policy to cover board approvals for the bidding of large projects and an internal policy and procedure which spells out additional requirements, like requiring three written bids for large purchases. In addition, all members...
Corrective action planned: Two new policies will be implemented; a board policy to cover board approvals for the bidding of large projects and an internal policy and procedure which spells out additional requirements, like requiring three written bids for large purchases. In addition, all members of the Board of Directors and senior leadership team will sign Conflict of Interest statements on an annual basis to confirm that they do not have any potential conflicts that could impact purchasing decisions. Anticipated completion date: July 31, 2025 Contact person responsible for corrective action: Steve Lindemann, Interim CFO
Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses...
Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses to verify that they are appropriate and in the correct accounting period. A procedure will be implemented to ensure that at year-end, all grant revenues and expenses are double-checked to verify they are posted in the correct period. Anticipated completion date: July 31, 2025 Contact person responsible for corrective action: Steve Lindemann, Interim CFO
2024-008 Untimely Submission of Single Audit Reporting Package to the Federal Audit Clearinghouse Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A procedure to ensure timely submission of reports and audit documentation will be implemented.
2024-008 Untimely Submission of Single Audit Reporting Package to the Federal Audit Clearinghouse Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A procedure to ensure timely submission of reports and audit documentation will be implemented.
2024-007 Missing Supporting Documentation for Federal Reimbursement Claims Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A process for retaining claims and supporting documentation has been implemented.
2024-007 Missing Supporting Documentation for Federal Reimbursement Claims Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A process for retaining claims and supporting documentation has been implemented.
View Audit 364023 Questioned Costs: $1
2024-006 Lack of Documentation for Supsension and Debarment Verification Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A process for documenting SAM.gov suspension and debarments will be implemented.
2024-006 Lack of Documentation for Supsension and Debarment Verification Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A process for documenting SAM.gov suspension and debarments will be implemented.
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.
2024-004 Lack of Documented Approval Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has implemented various approval and documentation procedures.
2024-004 Lack of Documented Approval Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has implemented various approval and documentation procedures.
2024-003 Inaccurate Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding and plans on creating a formal process for SEFA preparation. Training will be provided for responsible staff.
2024-003 Inaccurate Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding and plans on creating a formal process for SEFA preparation. Training will be provided for responsible staff.
Management’s Response/Corrective Action Plan (Unaudited): Future subrecipient contracts will include provisions requiring the submission of financial documentation in accordance with the requirements set forth in 2 CFR Part 200, Subpart F – Audit Requirements. Specifically, all subrecipients will be...
Management’s Response/Corrective Action Plan (Unaudited): Future subrecipient contracts will include provisions requiring the submission of financial documentation in accordance with the requirements set forth in 2 CFR Part 200, Subpart F – Audit Requirements. Specifically, all subrecipients will be required to submit either a fiscal year Profit and Loss Statement or, if applicable, a Single Audit report in accordance with the federal award expenditure thresholds established under 2 CFR § 200.501. These provisions ensure compliance with federal monitoring and oversight responsibilities and will be tailored to the subrecipient’s level of federal funding. Policies and procedures, including the Procurement Regulations manual are being updated to reflect these modifications. Planned Completion Date: These modifications are being implemented immediately and the documentation to update the policies and procedures will be updated by August 31, 2025. Contact Person Responsible for Correction Action: Leigha Boling, Division Director of Procurement & GrantsManagement or Designee
Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The re...
Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The report will then be completed and submitted as the official report. The approval will be documented via email or other written confirmation. All approval records will be saved in the designated quarterly report file at or before the time of submission. If another staff member prepares or adjusts the report (e.g., due to leave), they will also document and save evidence of approval in the designated quarterly report file. Moving forward, the City will consistently retain documented approvals as part of the reporting process. Planned Completion Date: These modifications are being implemented immediately. Contact Person Responsible for Correction Action: Joshua McAnarney, Division Director of Finance & Budget or Designee
Management’s Response/Corrective Action Plan (Unaudited): Bidding provisions for federally funded projects have been updated to include additional compliance requirements. All bidders are now required to submit documentation of their active registration in the System for Award Management (SAM.gov) a...
Management’s Response/Corrective Action Plan (Unaudited): Bidding provisions for federally funded projects have been updated to include additional compliance requirements. All bidders are now required to submit documentation of their active registration in the System for Award Management (SAM.gov) and verification of non-debarment status as part of their bid submission. During contract processing, City staff will log into SAM.gov to validate the bidder’s entity registration and confirm that the entity is not suspended or debarred from receiving federal awards, in accordance with 2 CFR § 180.300 and related provisions under 2 CFR Part 200. Policies and procedures, including the Procurement Regulations manual are being updated to reflect these modifications. Planned Completion Date: These modifications are being implemented immediately and the documentation to update the policies and procedures will be updated by August 31, 2025. Contact Person Responsible for Correction Action: Leigha Boling, Division Director of Procurement & Grants Management or Designee
B. Actions Planned or Taken: As of October 2024, the Town has adopted a Federal Procurement Policy.
B. Actions Planned or Taken: As of October 2024, the Town has adopted a Federal Procurement Policy.
Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the initial set up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Further, the Organizati...
Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the initial set up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Further, the Organization will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Anticipated Completion Date: 12/31/2024 Responsible Contact Person: Dr. David Sansoterra, Interim Chief Financial Officer
Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. ...
Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Anticipated Completion Date: 12/31/2024 Responsible Contact Person: Dr. David Sansoterra, Interim Chief Financial Officer
Finding 573174 (2024-003)
Significant Deficiency 2024
Views of Responsible Officials: Despite difficulty preparing the report within the timeframe requested, the grant was administered in accordance with Uniform Guidance and no questioned costs were identified. To assist with more efficient and accurate reports, AcademyHealth will begin implementing a ...
Views of Responsible Officials: Despite difficulty preparing the report within the timeframe requested, the grant was administered in accordance with Uniform Guidance and no questioned costs were identified. To assist with more efficient and accurate reports, AcademyHealth will begin implementing a new accounting system (Sage Intaact) in August 2025 which includes an integrated SEFA module to ensure complete and accurate reporting in future years.
Finding 573173 (2024-002)
Significant Deficiency 2024
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation wa...
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation was not available. In 2025, AcademyHealth initiated a new control under the direction of the Director of Grants and Contracts, Tamika King. On a monthly schedule, the Grants and Contracts Associate will prepare each payment request by reviewing timecard reports and reconciling costs to the Job Cost Transactions report. The Director of Grants and Contracts will subsequently review and log the prepared request. The log will be reviewed with the CFO and Senior Accounting Manager during the weekly cash flow meetings.
Finding 573172 (2024-001)
Significant Deficiency 2024
Views of Responsible Officials: A new indirect cost rate proposal to obtain final rates for 2019 through 2022 and requesting provisional rates for 2023 through 2025 was prepared by the previous CFO, Deborah Edwards and submitted by the current CFO, Holly Hueston on July 25, 2024. It was subsequently...
Views of Responsible Officials: A new indirect cost rate proposal to obtain final rates for 2019 through 2022 and requesting provisional rates for 2023 through 2025 was prepared by the previous CFO, Deborah Edwards and submitted by the current CFO, Holly Hueston on July 25, 2024. It was subsequently negotiated and approved in March 2025. AcademyHealth is currently working with an outsourced auditor to prepare a proposal to obtain final rates through 2024. In the future, the Chief Financial Officer will submit the indirect cost rate proposal to obtain final rates for the fiscal year just completed, and requests for provisional rates for upcoming years will be submitted within the required timeframe.
2024-003 – Reporting – Significant Deficiency Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization identified during the pre...
2024-003 – Reporting – Significant Deficiency Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization identified during the preparation of its second quarter 2024 expenditure report approximately $25,000 in costs incurred during November 2022 that had not previously been included in a submitted expenditure report to PCCD and which were included in the second quarter 2024 expenditure report. While such costs were incurred during the overall program performance period and were allowable and attributable to the program, such costs were not timely identified and reported on the correct expenditure report. Corrective Action Plan: To strengthen our internal controls and ensure full compliance with grantor reporting requirements, we are implementing the following corrective measures: 1. Review and Update of Reporting Procedures: o We will review and revise our existing grant expenditure reporting procedures to ensure that all expenditures are properly captured, reviewed, and reconciled before submission to the grantor. o Revised procedures will clearly define roles and responsibilities for program staff, grants management, and accounting. 2. Monthly Reconciliation Process: o A monthly reconciliation process will be implemented to match recorded expenditures in the general ledger with grant budgets and program activity. o Variances will be reviewed and resolved in advance of quarterly reporting deadlines to prevent errors in submitted reports. 3. Dual Review and Approval: o All quarterly expenditure reports will be subject to dual review by the grant’s accountant and the accounting operations manager prior to submission. o This control will ensure that reports are complete, accurate, and supported by accounting records. 4. Training and Communication: o Finance and program staff involved in grant administration and reporting will receive training on updated procedures and internal control expectations. o Ongoing communication between departments will be encouraged to ensure awareness of allowable costs, budget constraints, and reporting timelines. 5. System Enhancements: o We are evaluating our current financial system and looking for a system that will allow better tracking of grant-specific expenditures, including improved reporting functionality and coding accuracy.
2024-002 - Subrecipient Monitoring - Material Weakness/Noncompliance Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization do...
2024-002 - Subrecipient Monitoring - Material Weakness/Noncompliance Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization does not have a formal risk assessment or oversight program in place to monitor its subrecipients as required under the Uniform Guidance, including ensuring that financial information reconciles between the underlying expenditure reports and the subrecipient/Organization audit reports. Corrective Action Plan: CCAP will be implementing the following corrective actions: 1. Formalization of Subaward Documentation: o We will revise our subaward agreement templates to ensure that all required elements (as outlined in 2 CFR §200.331(a)) are explicitly included. o All subawards will clearly identify the agreement as a “subaward” and specify required data elements such as the Federal Award Identification Number (FAIN), CFDA/Assistance Listing number, period of performance, and applicable federal terms and conditions. 2. Subrecipient Risk Assessment Framework: o A standardized risk assessment tool is being developed and will be implemented for all subrecipients prior to executing a subaward. o This tool will evaluate prior audit history, organizational capacity, experience with federal funds, and other risk indicators as required by §200.331(b). 3. Monitoring and Oversight Procedures: o We are enhancing our subrecipient monitoring policy to include a tiered approach based on the results of the risk assessment. o Monitoring activities will include regular desk reviews, periodic programmatic and financial reporting, and site visits for high-risk subrecipients as per §200.331(d)-(e). 4. Audit Verification: o Our grants team will verify annually that each subrecipient subject to audit under Subpart F has completed the required Single Audit. o We will obtain and review audit reports and maintain documentation of our review in accordance with §200.331(f). 5. Results Review and Adjustments: o Any issues identified through audits, site visits, or other monitoring will be evaluated to determine if they necessitate changes in our records, subaward terms, or overall monitoring strategy (§200.331(g)). 6. Enforcement Procedures: o We are formalizing a process for escalating issues of noncompliance, including written warnings, corrective action plans, suspension of funds, or termination of subawards, as appropriate and consistent with §200.338.
2024-001 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: While the Organi...
2024-001 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: While the Organization has informal policies and procedures surrounding the administration of its federal programs, these policies and procedures have not been formally documented to ensure compliance with the areas of allowability of costs, cash management, procurement, travel, conflict of interest or subrecipient monitoring as required under the Uniform Guidance. Corrective Action Plan: To address this finding and strengthen our internal controls and compliance framework, CCAP will be implementing the following corrective actions: 1. Policy Development and Documentation: o We will be initiating a project to develop and formalize comprehensive written policies and procedures in the following required areas:  Allowability of Costs (2 CFR §200.403–§200.405)  Cash Management (2 CFR §200.305)  Procurement Standards (2 CFR §200.317–§200.326)  Travel Costs (2 CFR §200.474)  Conflict of Interest (2 CFR §200.112)  Subrecipient Monitoring (2 CFR §200.331–§200.333) o These policies will reference relevant Uniform Guidance sections and incorporate internal controls, approval processes, and documentation standards. 2. Internal Review and Approval: o Draft policies will be reviewed by senior leadership, legal counsel (if necessary), and the finance and grants teams to ensure alignment with regulatory requirements and operational realities. 3. Training and Dissemination: o Once finalized, all relevant staff (including program managers, finance personnel, and procurement staff) will receive training on the new policies. o Policies will be made available on CCAP’s intranet. 4. Ongoing Maintenance and Review: o A process will be established for annual review and update of these policies to incorporate regulatory changes and feedback from internal audits or grantor reviews.
Condition: Controls in place did not ensure the procurement policy was followed consistently. Planned Corrective Action: Management acknowledges the importance of adhering to the procurement policy and takes its compliance obligations seriously. Although this particular finding did not result in non...
Condition: Controls in place did not ensure the procurement policy was followed consistently. Planned Corrective Action: Management acknowledges the importance of adhering to the procurement policy and takes its compliance obligations seriously. Although this particular finding did not result in noncompliance, management recognizes that a recurrence could lead to noncompliance. To prevent future occurrences, management is committed to enhancing internal controls. The following corrective actions will be implemented to ensure consistent adherence to procurement standards: 1. Update purchasing policies, procedures, forms, and job aides to enhance the clarity of requirements, particularly requirements for blanket purchase orders. Target completion date: 6/30/2025 2. Retrain agency staff, purchasing staff, and accounts payable staff on their roles and responsibilities related to purchasing policies. Target completion date: 7/31/2025 3. Implement a monthly review process for all vouchers posted against blanket POs to verify compliance. Target completion date: 7/31/2025 4. Update standard terms and conditions for blanket purchase orders (POs) to prohibit any purchase under a blanket PO from exceeding $10,000, and communicate this limit to all vendors with open blanket POs, requiring an acknowledgement of this change of terms. Failure to return the acknowledgement will result in closure of the blanket PO. Target completion date: 9/30/2025 5. Investigate the feasibility of implementing a system control within the purchasing system to require review and approval of requisitions by senior staff or management prior to PO issuance. Target completion date: 8/31/2025 Contact person responsible for corrective action: Prerna Russell Anticipated Completion Date: 09/30/2025
Condition: Controls in place did not ensure a foreign national employee's involvement on a project were communicated to the Contracts Manager for tracking. Planned Corrective Action: Management takes its responsibility to comply with the terms and conditions of awards seriously, and, while this part...
Condition: Controls in place did not ensure a foreign national employee's involvement on a project were communicated to the Contracts Manager for tracking. Planned Corrective Action: Management takes its responsibility to comply with the terms and conditions of awards seriously, and, while this particular finding did not result in noncompliance with the terms of an award, a repeat occurrence could result in noncompliance. To prevent future occurrences, management will enhance internal controls to ensure consistent tracking and reporting of foreign nationals working on Department of Energy sponsored projects by taking the following corrective actions by July 31, 2025: 1) Update the company’s policy for tracking and reporting foreign nationals to include: a) A requirement that all team members must be approved by Contract Services before starting work on a DOE project. b) A requirement that Contract Services review a payroll report monthly to ensure all individuals who charged time to DOE projects were pre-approved. 2) Train business unit leaders, project managers, and contract services staff on the revised policy and procedures for tracking and reporting foreign nationals. Contact person responsible for corrective action: Prerna Russell Anticipated Completion Date: 07/31/2025
The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management wh...
The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management which expanded the scope of the financial review. As a result of these monitoring efforts, the Corporation identified ineligible and questioned costs, and efforts are underway to recapture ineligible and unsupported costs. The Corporation has put the following policies and procedures in place to mitigate future risk: 1. Biennial Risk Assessment with Annual Updates 2. Annual Project Compliance Report (APCR) required by subrecipient agencies (with the exception of subrecipients receiving only Department of Energy and LIHEAP grants for the Weatherization Assistance Program, which are governed by separate monitoring procedures). 3. Enhanced Draw Monitoring and draw documentation requirements 4. Expansion of the Corporation’s Compliance and Training Team Given the policies, procedures, and changes outlined above, the Corporation feels confident it will be able to comply with its Compliance Monitoring Plan going forward and identify any concerns with subrecipient compliance in a timely manner. Curtis Stauffer, Managing Director, Housing Contract Administration, and applicable compliance staff will implement by October 1, 2024.
View Audit 363980 Questioned Costs: $1
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