Corrective Action Plans

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Finding 24824 (2022-001)
Significant Deficiency 2022
Finding #2022-001- Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control ov...
Finding #2022-001- Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or can both make and conceal an error, whether such error is intentional or unintentional. Condition: A properly designed system of internal control includes adequate staffing, policies, and procedures to properly segregate duties. All internal control duties can be classified into four broad categories: authorization, custody, recordkeeping, and reconciliation. No one person should have control of two or more of these four categories for any one cycle. There are key controls related to significant transaction cycles that are important in reducing the risk of errors or irregularities. Currently, there are the following overlapping duties: - Both Accounting Specialists have the authority to enter invoices into the system, print checks, and have access to the electronic signatures. Preferably, the check cutting process would separate the entering of payment information into the system and the ability to print signed checks. - One Accounting Specialist creates deposits and makes deposits with the bank. Although not the standard procedure, the Accounting Specialist has the authority to collect cash receipts. Ideally, separate individuals would collect cash and make deposits. - The Housing Authority Executive Director opens the mail, creates deposits and takes deposits to the bank. The Executive Director also enters invoices into the system and prints checks. The Board of Commissioners approves disbursements and all checks require dual signatures. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities because of the lack of segregation of duties. Cause: Limited number of personnel. Recommendation: We recommend that the City consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with this finding but do not believe it is cost effective to increase personnel to bring about a more effective segregation of duties.
Finding 24819 (2022-061)
Significant Deficiency 2022
Finding 2022-061 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Subrecipient Audits Management Views MSP agrees with the finding. Planned Corrective Action MSP will improve monitoring by reconciling expenditures by program to ensure that all subrecipients ar...
Finding 2022-061 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Subrecipient Audits Management Views MSP agrees with the finding. Planned Corrective Action MSP will improve monitoring by reconciling expenditures by program to ensure that all subrecipients are included on the single audit tracking sheet for review. In addition, MSP will transition to each division having the responsibility for the completion of their own single audit reviews beginning October 1, 2023. Anticipated Completion Date MSP will reconcile expenditures by program by October 1, 2023, and each division will have their single audit reviews completed by September 30, 2024. Responsible Individual(s) Matt Opsommer, MSP
Finding 24818 (2022-060)
Significant Deficiency 2022
Finding 2022-060 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - FFATA Reporting Management Views MSP agrees with the finding. The fiscal year 2022 exceptions identified in the audit finding occurred prior to the implementation of corrective action for the fis...
Finding 2022-060 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - FFATA Reporting Management Views MSP agrees with the finding. The fiscal year 2022 exceptions identified in the audit finding occurred prior to the implementation of corrective action for the fiscal year 2021 finding. Planned Corrective Action MSP has hired a Department Technician whose responsibilities will include the task of FFATA reporting. MSP will review the procedure for FFATA reporting for additional efficiencies to ensure timeliness. In addition, MSP is implementing a grants management system that will include FFATA reporting functionality. Anticipated Completion Date MSP will make any needed updates to the procedure and anticipates having the grants management system implemented by September 30, 2023. Responsible Individual(s) Penny Burger, MSP
Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibil...
Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end date of the PHE, as MDHHS completes renewals for existing cases. MDHHS could not terminate Medicaid benefits during the PHE, and annual renewals have not been completed since the start of the PHE, resulting in most Medicaid cases not being touched until the 14-month unwind period allotted by the Centers for Medicare and Medicaid Services at the end of the PHE. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children?s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 31, 2024 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Erin Emerson, MDHHS
Finding 24783 (2022-059)
Significant Deficiency 2022
Finding 2022-059 Social Services Block Grant, ALN 93.667 - Post-Expenditure Report Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS revised its methodology to include Independent Living Services recipients in the Social Services Block Grant (SSBG) Post-Expenditure ...
Finding 2022-059 Social Services Block Grant, ALN 93.667 - Post-Expenditure Report Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS revised its methodology to include Independent Living Services recipients in the Social Services Block Grant (SSBG) Post-Expenditure Report. In addition, MDHHS revised and re-submitted the fiscal year 2022 SSBG Post-Expenditure Report with the correct recipient counts. Anticipated Completion Date Completed Responsible Individual(s) Emiliza Noel, MDHHS Tiffany Clarke, MDHHS Rebecca Jones, MDHHS
Contact Person ? Jeannie Mayer, Superintendent Corrective Action Plan ? The District will review policies and procedures for submitting meal counts for reimbursement. Completion Date ? November 1, 2022
Contact Person ? Jeannie Mayer, Superintendent Corrective Action Plan ? The District will review policies and procedures for submitting meal counts for reimbursement. Completion Date ? November 1, 2022
Finding 24771 (2022-001)
Significant Deficiency 2022
Comments on Findings and Recommendation: The Corporation's required deposit into the residual receipts account per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should make all required residual ...
Comments on Findings and Recommendation: The Corporation's required deposit into the residual receipts account per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should make all required residual receipts deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after the fiscal year end. Action(s) taken or planned on the finding: Agree. Management deposited $10,879 into the residual receipts fund on May 2, 2022.
View Audit 23406 Questioned Costs: $1
Finding 2022-002: Compliance around Physical Inventory CFDA. 93.600 Agency. Department of Health and Human Services Immaterial Noncompliance: The last inventory of assets was completed in the fiscal year ending January 31, 2020. Recommendation: Inventory should be done at least every two years a...
Finding 2022-002: Compliance around Physical Inventory CFDA. 93.600 Agency. Department of Health and Human Services Immaterial Noncompliance: The last inventory of assets was completed in the fiscal year ending January 31, 2020. Recommendation: Inventory should be done at least every two years and reconciled with the property records at least once every two years. Corrective Action: An inventory of assets will be completed. Anticipated Completion Date: December 31, 2022
Finding 2022-001: Review of expense allocations CFDA. 93.600 Agency. Department of Health and Human Services Significant Deficiency: There was inconsistent documentation of allocation rates for invoices charged to the grant. Allocations other than the rates determined by management were used on f...
Finding 2022-001: Review of expense allocations CFDA. 93.600 Agency. Department of Health and Human Services Significant Deficiency: There was inconsistent documentation of allocation rates for invoices charged to the grant. Allocations other than the rates determined by management were used on five out of forty nonpayroll expenses. Recommendation: System allocations should be reviewed regularly by an appropriate member of management and invoice allocations should be consistent with the approved allocations. Corrective Action: Clackamas County Children?s Commission (CCCC) agrees with the auditors? findings, and the following action will be taken to improve the situation. Allocations, and the supporting documentation for how those were derived will be periodically printed to PDF format for historical recording of changes, and the dates any changes were made. We will review the allocation codes of the accounting system monthly and deactivate those that we are not going to use in order to avoid errors in the allocation of expenses. Additionally, we will continue to review the transactions prior to posting in the accounting system to correct any errors. Anticipated Completion Date: September 2022
Finding Number: 2022-001 Planned Corrective Action: The District has added additional language to the federal procurement checklist to ensure that all federal contracts are compliant with Federal Prevailing wage rate requirements. Anticipated Completion Date: Immediately Responsible Contact Per...
Finding Number: 2022-001 Planned Corrective Action: The District has added additional language to the federal procurement checklist to ensure that all federal contracts are compliant with Federal Prevailing wage rate requirements. Anticipated Completion Date: Immediately Responsible Contact Person: Nicole Cottrell, cottrellnl@scsdoh.org, (937) 505-2825
The District will review compliance requirements to ensure all compliance requirements are met.
The District will review compliance requirements to ensure all compliance requirements are met.
The District will review compliance requirements to ensure all compliance requirements are met and will implement changes going forward to ensure personnel expense (time and effort) is documented.
The District will review compliance requirements to ensure all compliance requirements are met and will implement changes going forward to ensure personnel expense (time and effort) is documented.
Management will reinforce procedures to ensure all grant reports are submitted by the required due date.
Management will reinforce procedures to ensure all grant reports are submitted by the required due date.
Identifying Number: 2022-001 Finding: The Organization did not deposit cash surplus into the residual receipts account in a timely manner. Contact Person Responsible for Corrective Action: Richard Manall, CFO Corrective Action Taken or Planned: Review of the financial statement now includes the proc...
Identifying Number: 2022-001 Finding: The Organization did not deposit cash surplus into the residual receipts account in a timely manner. Contact Person Responsible for Corrective Action: Richard Manall, CFO Corrective Action Taken or Planned: Review of the financial statement now includes the process of making the cash surplus cash transfer into the residual receipts account. Anticipated Completion Date: September 14, 2022.
Finding 24737 (2022-058)
Significant Deficiency 2022
Finding 2022-058 Low Income Home Energy Assistance, ALN 93.568 - Annual Report on Households Assisted by LIHEAP Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS and DTMB plan to improve communication with Treasury to help ensure that accurate data is received prior t...
Finding 2022-058 Low Income Home Energy Assistance, ALN 93.568 - Annual Report on Households Assisted by LIHEAP Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS and DTMB plan to improve communication with Treasury to help ensure that accurate data is received prior to the report submission. MDHHS will also evaluate the Interagency Agreement and determine if changes are needed. In addition, DTMB is currently evaluating the cause of query inaccuracies and plans to make necessary changes to the query. Anticipated Completion Date MDHHS and DTMB will coordinate with Treasury to clarify when the data is needed for the report by July 31, 2023. MDHHS will evaluate and make changes to the fiscal year 2024 Interagency Agreement by September 30, 2023. DTMB will make necessary changes to the query by December 1, 2023. Responsible Individual(s) Denise Hawkins, DTMB Julie McLaughlin, MDHHS
Finding 2022-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and mainta...
Finding 2022-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support State Emergency Relief (SER) processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Beginning in fiscal year 2023, MDHHS implemented quarterly case reads and during April 2023, MDHHS began monthly meetings with BSCs to discuss the results of quarterly SER case reads. In addition, MDHHS will update SER policy to include additional verification sources. Anticipated Completion Date MDHHS will update policy by September 30, 2023. All other corrective action is ongoing. Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS
View Audit 20093 Questioned Costs: $1
Finding 24735 (2022-056)
Significant Deficiency 2022
Finding 2022-056 Low-Income Home Energy Assistance, ALN 93.568 - Recertification of Clearance Patterns Management Views Treasury agrees with the finding. Unforeseen reorganizational efforts and staffing turnover in fiscal year 2022 resulted in a disruption to the continuality of the Cash Manageme...
Finding 2022-056 Low-Income Home Energy Assistance, ALN 93.568 - Recertification of Clearance Patterns Management Views Treasury agrees with the finding. Unforeseen reorganizational efforts and staffing turnover in fiscal year 2022 resulted in a disruption to the continuality of the Cash Management Improvement Act program. Corrective action implemented to address prior audit findings enabled newly appointed staff to replicate queries for most of the programs that required clearing pattern review. As a result, the number of programs exhibiting significant deficiencies in their clearance pattern review decreased compared to fiscal year 2021. Planned Corrective Action Treasury will continue updating the procedures pertaining to the verification processes of clearing patterns and will prioritize the examination of queries from SBI to ensure that Treasury data includes all required clearing patterns for review. Clearing Pattern Recertification is mandated by the federal government every five years. Internally, annual reviews of clearing patterns will be conducted to ensure adherence to the program's objectives. State agencies will continue to provide the necessary coding and date range information for the development of clearing patterns. Anticipated Completion Date Treasury will make updates to the procedures and complete the clearing pattern review by September 2023. Responsible Individual(s) Andrew Silva, Treasury
Finding 24719 (2022-055)
Significant Deficiency 2022
Finding 2022-055 Temporary Assistance for Needy Families, ALN 93.558 - Accuracy of Financial Reports Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will revise the financial reports for the quarters ending September 30, 2022, and December 31, 2022, and submit to t...
Finding 2022-055 Temporary Assistance for Needy Families, ALN 93.558 - Accuracy of Financial Reports Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will revise the financial reports for the quarters ending September 30, 2022, and December 31, 2022, and submit to the U.S. Department of Health and Human Services Administration for Children and Families by May 15, 2023. MDHHS will also evaluate the internal control approval process and determine if any changes are needed. Anticipated Completion Date MDHHS will complete its evaluation of the internal control approval process by September 30, 2023, and will then develop a timeline for implementing changes identified during the evaluation, if applicable. Responsible Individual(s) Rebecca Jones, MDHHS Tiffany Clarke, MDHHS Emiliza Noel, MDHHS
Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing st...
Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent out to the local offices. ESA leadership will reach out to the managers of the individual specialists regarding the issues identified and provide additional guidance. Anticipated Completion Date Training will be ongoing. ESA will issue the memorandum and address the specific issues with local office management and specialists by August 31, 2023. Responsible Individual(s) Kenton Schulze, MDHHS Lana Karadsheh, MDHHS Brian Sanborn, MDHHS
View Audit 20093 Questioned Costs: $1
Item 2022-003 Reporting ? Management?s Response ? The Agency will implement controls to ensure proper review and approval is obtained on required grant reports prior to submission to the grantor. Anticipated Completion: September 30, 2023 Responsible Party: Belinda Mitchell, Executive Director
Item 2022-003 Reporting ? Management?s Response ? The Agency will implement controls to ensure proper review and approval is obtained on required grant reports prior to submission to the grantor. Anticipated Completion: September 30, 2023 Responsible Party: Belinda Mitchell, Executive Director
Item 2022-002 (Repeat 2021-001) Reporting ? Management?s Response ? Management concurs with the finding. The Agency encountered technical difficulties when attempting to submit the report and is currently seeking the assistance of their representative at Region Four to assist with completing the fil...
Item 2022-002 (Repeat 2021-001) Reporting ? Management?s Response ? Management concurs with the finding. The Agency encountered technical difficulties when attempting to submit the report and is currently seeking the assistance of their representative at Region Four to assist with completing the filing requirement. The grants manager has become aware of the due date for the SF429 and where it is to be submitted and will take full responsibility for the completion and the uploading of this report. Anticipated Completion: September 30, 2023 Responsible Party: Belinda Mitchell, Executive Director
Finding 24714 (2022-002)
Material Weakness 2022
Finding Number: 2022-002 Finding Title: Eligibility Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Penny Messer, Health and Human Services Division Leader, and Karrie Kolb, Financial Assistance Supervisor Corrective Action Planned: The errors from this rev...
Finding Number: 2022-002 Finding Title: Eligibility Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Penny Messer, Health and Human Services Division Leader, and Karrie Kolb, Financial Assistance Supervisor Corrective Action Planned: The errors from this review will be thoroughly discussed at the next all unit meeting. The Income Maintenance Supervisor plans to meet with each worker independently to review the errors and ensure understanding of policy and requirements, and a coaching plan will be implemented with each employee that had two or more case errors. Additionally, the Income Maintenance unit will conduct an average of 15 case reviews on a quarterly basis. Anticipated Completion Date: These actions were implemented on June 6, 2023, and the case reviews will begin in the third quarter of 2023, and be completed on an ongoing basis thereafter.
Finding 24685 (2022-001)
Material Weakness 2022
Guild
MN
Finding 2022-001 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified five instances where the participant?s file did not have documentation that the rent reasonableness test was ...
Finding 2022-001 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified five instances where the participant?s file did not have documentation that the rent reasonableness test was performed in a timely manner. In addition, we identified 19 instances where the participant?s file did not have documentation that the rent reasonableness test was reviewed. Creating Inadequate internal controls over compliance could result in noncompliance with the federal program. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: A complete review and policy and procedures along with proper training for new staff. The findings occurred during position vacancy and onboarding training. Additional steps are taken to ensure training is completed and random spot checks of client files. Anticipated Completion Date: Ongoing in nature.
Finding 24684 (2022-002)
Significant Deficiency 2022
Guild
MN
Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Org...
Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Organization?s documentation. In addition, there was no indication that a review was performed of the information submitted for one of the four months tested, which resulted in the reimbursement amount from the pass-through entity being more than the support maintained by the Organization for three of the 12 months and no documentation of the review for one of the months. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: Schedule meetings with 3rd party vendor to identify the significant rounding errors occurring. Develop an agreement on rounding procedures to be used by both parties ensuring reconciliation. Anticipated Completion Date: 12/31/23 ? Note- this system of reimbursement terminated on 3/31/23
Finding 24681 (2022-008)
Significant Deficiency 2022
Finding 2022-008 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with parts a., b., d., and e. of the finding. DTMB disagrees with part c. of the finding. For part c., although MDHHS and DTMB had not fully documented all database specific configuration standards unti...
Finding 2022-008 MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with parts a., b., d., and e. of the finding. DTMB disagrees with part c. of the finding. For part c., although MDHHS and DTMB had not fully documented all database specific configuration standards until after the audit period, DTMB disagrees that during the audit period the system contained potentially vulnerable database configurations and disagrees that DTMB cannot ensure the security of the data. DTMB has been and continues to implement the manufacturer?s recommendations regarding security configurations. In addition, the databases reside in restricted trusted internal security zones, protected by firewalls, which are specific to each application and database, in conjunction with intrusion protection, antivirus software, and SOM standard security safeguards. Planned Corrective Action For parts a. and e., MDHHS will continue to provide training for LOSCs via quarterly webinars to emphasize the proper procedures for granting access and how to review and compare access to DSA approved requests. For part b., MDHHS will add an Incompatible Role form into the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request with automated routing for appropriate approval. This would ensure that documentation was maintained, and appropriate approvals secured in all situations. For part c., DTMB developed an organization-wide framework for database security configuration management. For part d., MDHHS has implemented a quarterly report in MiSACWIS that will identify any financial authorization that was approved by the same person that created the authorization. Anticipated Completion Date a. and e. Corrective action is ongoing. b. MDHHS has not yet determined an anticipated completion date because implementation is dependent on funding, approval, and prioritization of proposed system changes. c. DTMB anticipates having compliance documentation by September 30, 2023. d. MDHHS will receive the first quarterly report on September 30, 2023, and will perform a review of the transactions identified on that report during October 2023. Responsible Individual(s) a., b., and e. Alana Lowe and Deon Nelson, MDHHS c. Heather Frick and Nathan Buckwalter, DTMB d. Alana Lowe, MDHHS
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