Corrective Action Plans

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Admin Offices 4301 S Cowan Rd Muncie, IN 47302 765-747-5222 office CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2025 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Progr...
Admin Offices 4301 S Cowan Rd Muncie, IN 47302 765-747-5222 office CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2025 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2025 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Significant Deficiency Context: During testing of allowable activities and costs, it was observed that the School Corporation allocated payroll and benefit expenses to the school lunch fund for the employee overseeing the food service management company. Five payroll transactions totaling $5,476 were selected for testing. For each transaction tested, the School Corporation allocated 18% of the employee’s time to the school lunch fund. Although the employee completed an annual self-certification estimating time spent on food service duties, there was no detailed time and effort log to support actual hours worked. Additionally, no internal control existed to provide a documented secondary review of the self-certification for accuracy and completeness. Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: 765-747-5222 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will no longer charge any payroll and benefit expenses to the school lunch fund. Anticipated Completion Date: July 1, 2025.
View Audit 373490 Questioned Costs: $1
Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and ac...
Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.
Kleeman Village Housing Corporation, NFP respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2025. The findings from the June 30, ...
Kleeman Village Housing Corporation, NFP respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2025. The findings from the June 30, 2025 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings - Financial Statement Audit: 2025 - 001 Response: Management agent and sponsor will continue to monitor financial reports and accounting information as correction is not practical.
Management plans to develop proper written policies and procedures for internal control over compliance to ensure accuracy and completeness in the preparation of the schedule as required by Uniform Guidance.
Management plans to develop proper written policies and procedures for internal control over compliance to ensure accuracy and completeness in the preparation of the schedule as required by Uniform Guidance.
Finding 1163624 (2025-001)
Material Weakness 2025
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
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View Audit 373396 Questioned Costs: $1
SEE CORRECTIVE ACTION PLAN
SEE CORRECTIVE ACTION PLAN
View Audit 373396 Questioned Costs: $1
Westwood Community Schools respectfully submits the following corrective action plan for the year ended June 30, 2025. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, Michigan 48912 Audit Period: Year ended June 30, 2025 District Contact Person: Jennie Li Jiang, Director of Fi...
Westwood Community Schools respectfully submits the following corrective action plan for the year ended June 30, 2025. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, Michigan 48912 Audit Period: Year ended June 30, 2025 District Contact Person: Jennie Li Jiang, Director of Finance and Operations The findings from the June 30, 2025 schedule of findings and responses are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding - Federal Award Findings and Question Costs Finding 2025-001: Considered a significant deficiency in internal control over compliance. Recommendation: The District should conduct a thorough review of cash drawdown procedures to ensure that drawdowns align with the expenditures incurred prior to the withdrawal of funds. Action to be taken: Management concurs with this finding and is implementing procedures to ensure compliance with cash management guidelines.
Action to be taken in response to the finding: To ensure timely submission of all required federal grant reports, the following procedures will be implemented immediately: 1. Centralized Federal Reporting Calendar ○ All federal grant reporting deadlines will be entered into a shared compliance calen...
Action to be taken in response to the finding: To ensure timely submission of all required federal grant reports, the following procedures will be implemented immediately: 1. Centralized Federal Reporting Calendar ○ All federal grant reporting deadlines will be entered into a shared compliance calendar maintained by the grants team. ○ Reminder alerts will be scheduled for 30 days, 14 days, and 7 days before each reporting deadline.2. Assignment of Responsible Parties ○ Primary Responsible Staff: Dr. Jenny Jasper (CFO) will be responsible for preparing and submitting all federal grant reports. ○ Secondary Reviewer: Adrian Lovett (Operations Director) will review each report for accuracy and ensure that deadlines are met. ○ This dual responsibility ensures continuity in case of staff absence. 3. Internal Early Deadline Requirement ○ All federal reports must be completed and ready for review no later than five business days prior to the official deadline. ○ This internal buffer will allow time for revisions, approval, and confirmation of submission. 4. Verification and Documentation of Submission ○ Both the primary and secondary staff members will verify that the report has been successfully submitted in the federal reporting system. ○ Submission confirmations will be saved in a designated grants compliance folder as part of our official record. Management view of the finding: We recognize the importance of timely and accurate submission of all federal grant reports. The delay identified in the audit does not reflect our expectations for compliance, and we are committed to implementing corrective measures to prevent recurrence. Therefore, we do not disagree with the finding.
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g...
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Recommendation – We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual. Views of Responsible Officials and Planned Corrective Actions – CCI is implementing a system update within eCW to ensure the sliding fee schedule is accurately configured and consistently applied across all service locations. As part of this corrective action, CCI is developing a formal training program to ensure that all applicable employees understand the sliding fee requirements and possess the necessary knowledge to follow the established procedures. CCI is also establishing an internal review process to monitor compliance with the sliding fee policy. This process will include periodic sampling and review of sliding fee scale assessments to verify that eligibility determinations and discounts are being applied correctly and in accordance with policy. Any identified discrepancies will be addressed through targeted staff retraining or process adjustments, as appropriate. These corrective actions are designed to strengthen internal controls, ensure consistent application of the sliding fee program, and maintain compliance with regulatory and organizational requirements. Reason for Recurrence – CCI experienced significant turnover within the Revenue Cycle Department during fiscal year 2025, which contributed to delays in updating system configurations and conducting required reviews. Anticipated Completion/Implementation Date: End of Fiscal Year 2026
2025-002/2024-002/2023-009 Health Center Program Cluster – ALN Nos. 93.224 and 93.527U.S. Department of Health and Human Services Award No. H80CS10591Program Year 16 and 17 Family Planning Services – ALN No. 93.217 U.S. Department of Health and Human Services Award No. FPHPA006584 Program Year 3 and...
2025-002/2024-002/2023-009 Health Center Program Cluster – ALN Nos. 93.224 and 93.527U.S. Department of Health and Human Services Award No. H80CS10591Program Year 16 and 17 Family Planning Services – ALN No. 93.217 U.S. Department of Health and Human Services Award No. FPHPA006584 Program Year 3 and 4 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained. Views of Responsible Officials and Planned Corrective Actions – CCI Health Services will strengthen its processes to ensure all UDS, FFR, and FCTR reports are prepared using accurate financial information supported by appropriate documentation. A standardized federal reporting checklist is being developed to identify required data sources, outline reconciliation steps, and document preparer and reviewer responsibilities. All reports will be reconciled to the system reports and reviewed by both the Controller and CFO before submission to ensure accuracy and completeness. Supporting documentation for all federal reports will be maintained in a centralized location to ensure consistency and future audit readiness. Reason for Recurrence – CCI experienced significant turnover in the Finance Department during fiscal year 2025, which contributed to delays and difficulties in locating supporting documentation for federal reports. Anticipated Completion/Implementation Date: End of Fiscal Year 2025
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Corrective Action Plan (CAP) The Housing Authority of the City of Ozark, Alabama (Housing Authority) To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended March 31, 2025 financial statements, it was determined that the Housing Authority did...
Corrective Action Plan (CAP) The Housing Authority of the City of Ozark, Alabama (Housing Authority) To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended March 31, 2025 financial statements, it was determined that the Housing Authority did not perform annual HQS inspections for all units or conduct HQS re-inspections during the 30-day period required by HUD. Dannie Walker, Executive Director is responsible for implementing the corrective action plan. CAP developed to resolve audit findings: Finding 2025-001 - Section 8 HQS Inspection Deficiencies We concur with the recommendation and we will establish controls that ensure that annual inspection are performed, re-inspections are performed within the 30-day requirement and that HAP abatements are properly assessed. The Housing Authority is also planning on additional training for employees to make sure they are qualified to meet the HQS re-inspection requirements.
Management of Jasper County REMC will implement procedures to ensure that required documents are obtained prior to services being performed. Management agrees with the findings.
Management of Jasper County REMC will implement procedures to ensure that required documents are obtained prior to services being performed. Management agrees with the findings.
Management of Jasper County REMC was aware of lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate duties at this time. Management agrees with the findings.
Management of Jasper County REMC was aware of lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate duties at this time. Management agrees with the findings.
Corrective Action Management has responded to all of the Department of Labor’s Findings as of October 9, 2025, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of the date of this Report. The Authority’s Chief Executive Officer has assumed the ...
Corrective Action Management has responded to all of the Department of Labor’s Findings as of October 9, 2025, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of the date of this Report. The Authority’s Chief Executive Officer has assumed the responsibility of continued execution of the corrective actions.
FINDING 2025-001 Corrective Action Plan Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe s...
FINDING 2025-001 Corrective Action Plan Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe set by HUD. Responsible party: Kayla Thurlow, Controller; (207) 373-1140 Anticipated completion date: No later than September 30, 2025
View Audit 373280 Questioned Costs: $1
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discou...
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discount Program (SFDP) policies, procedures, and forms for better clarity and tracking. - Continue to perform monthly internal audits of sliding fee transactions and document audit findings, corrective actions, and report results to leadership. - Retrain current staff quarterly based on the monthly internal audit results. - Train all new staff at new hire orientations. - Validate staff understanding through annual knowledge checks and competency assessments. - Integrate SFDP compliance into staff performance evaluations. - Maintain centralized log of all SFDP applications and determinations. Proposed Completion Date: December 31, 2025
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring C...
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Food and Nutrition Service Coordinator. 4. Planned Completion Date for CAP The CAP was implemented immediately during audit fieldwork performed in October 2025. 5. Plan to Monitor Completion of CAP The Food and Nutrition Service Coordinator will continually review applications and supporting documentation for completion and eligibility accuracy. Any issues noted will be communicated to appropriate staff and fixed immediately.
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
View Audit 373203 Questioned Costs: $1
Implementation plan of action: The Business Manager will review these requirements with the Sr. Account Clerk. The Sr. Account Clerk will verify that all vendors are eligible to participate in the federal assistance program on an annual basis. Specifically, a note will be entered on the vendor recor...
Implementation plan of action: The Business Manager will review these requirements with the Sr. Account Clerk. The Sr. Account Clerk will verify that all vendors are eligible to participate in the federal assistance program on an annual basis. Specifically, a note will be entered on the vendor record in the accounting system each time a purchase order is issued, which will detail that the proper verification was performed. Person Responsible for Implementation: Jodi Birch, Business Manager and Amanda Lestage, Sr. Account Clerk Anticipated Completion Date: August 30, 2025
We have posted the adjustments recommended by the auditors and management will implement the following control: Management agent will refund $48,720 in fees to the project and conduct staff training on monthly and annual procedures over financial close and reporting by October 31, 2025.
We have posted the adjustments recommended by the auditors and management will implement the following control: Management agent will refund $48,720 in fees to the project and conduct staff training on monthly and annual procedures over financial close and reporting by October 31, 2025.
View Audit 373145 Questioned Costs: $1
Records & Registration will now submit modified enrollment files as Graduates Only records to ensure accurate and timely graduation status updates. This solution has been confirmed by NSC. Additional staff have been trained on the updated procedures, and new processes are in place to ensure discrepa...
Records & Registration will now submit modified enrollment files as Graduates Only records to ensure accurate and timely graduation status updates. This solution has been confirmed by NSC. Additional staff have been trained on the updated procedures, and new processes are in place to ensure discrepancies and error flags are resolved promptly. Records & Registration and the Financial Aid Office continue to collaborate to identify and address discrepancies that may affect Title IV eligibility. Person(s) Responsible: Assistant Registrar, Director of Financial Aid Timing for Implementation: Immediate
MANAGEMENT AGREES WITH THE FINDING. THE RELATED PROJECT WILL REIMBURSE THE PROJECT FOR THE RENTS IN THE AMOUNT OF $14,054.
MANAGEMENT AGREES WITH THE FINDING. THE RELATED PROJECT WILL REIMBURSE THE PROJECT FOR THE RENTS IN THE AMOUNT OF $14,054.
View Audit 373083 Questioned Costs: $1
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