Corrective Action Plans

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The issue has been corrected and reporting will be accurate for 2025.
The issue has been corrected and reporting will be accurate for 2025.
Name of Contact Person: Hugh Chisholm, Chief Financial Officer Planned Corrective Action: Kaleida Health management asserts that the methodology applied to estimate and account for potential duplication of benefits with patient care revenue for FEMA Public Assistance Project #694036 was reasonable, ...
Name of Contact Person: Hugh Chisholm, Chief Financial Officer Planned Corrective Action: Kaleida Health management asserts that the methodology applied to estimate and account for potential duplication of benefits with patient care revenue for FEMA Public Assistance Project #694036 was reasonable, allowable, and consistent with FEMA guidance. The project was previously reviewed, approved, obligated, funded, and closed out by FEMA. A formal appeal of FEMA’s subsequent recommended reduction was filed in September 2025. Management continues to cooperate fully with FEMA and the New York State Division of Homeland Security and Emergency Services during the appeal process. Accordingly, corrective action is contingent upon FEMA’s final determination. Planned Completion Date: Not applicable. Management will evaluate the need for any corrective action upon receipt of FEMA’s final determination on the pending appeal.
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for severa...
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for several years. On July 27, 2025, the building experienced a roof leak causing a catastrophic flood. The building was evacuated and the Office of State Superintendent (OSSE) notified. OSSE sent an inspector to the site the following day who declared the building unsafe for occupancy. The Church was unable to cover any costs for the necessary repairs. On July 30, 2025 the Board of Directors made the difficult decision to suspend operations, but to continue as a Board, maintain the Center’s 501(c)3 status and its corporate registration. Furthermore, the Board is using this time to research current community needs, space availability and cost, and the effect of the Federal government’s waning support for early childhood education. Once this exercise is complete, the Board will determine the Center’s ability to reopen in an alternate site and address the findings in an appropriate manner.
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for severa...
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for several years. On July 27, 2025, the building experienced a roof leak causing a catastrophic flood. The building was evacuated and the Office of State Superintendent (OSSE) notified. OSSE sent an inspector to the site the following day who declared the building unsafe for occupancy. The Church was unable to cover any costs for the necessary repairs. On July 30, 2025 the Board of Directors made the difficult decision to suspend operations, but to continue as a Board, maintain the Center’s 501(c)3 status and its corporate registration. Furthermore, the Board is using this time to research current community needs, space availability and cost, and the effect of the Federal government’s waning support for early childhood education. Once this exercise is complete, the Board will determine the Center’s ability to reopen in an alternate site and address the findings in an appropriate manner.
2024-007 Untimely Submission of Project and Expenditure Report: Management acknowledges the finding related to the untimely submission of the American Rescue Plan Act (ARPA) Project and Expenditure Report. To address this issue and prevent future occurrences, the City is implementing an ARPA reporti...
2024-007 Untimely Submission of Project and Expenditure Report: Management acknowledges the finding related to the untimely submission of the American Rescue Plan Act (ARPA) Project and Expenditure Report. To address this issue and prevent future occurrences, the City is implementing an ARPA reporting process that clearly defines reporting requirements, deadlines, and responsible personnel, along with a centralized compliance calendar to track all federal grant reporting deadlines and provide reminders to ensure timely submission. Primary responsibility for ARPA reporting has been assigned to designated Finance Department staff, with supervisory review by senior management to ensure reports are complete, accurate, and submitted on time. In addition, Finance staff have received training on federal and ARPA specific reporting requirements, and cross-training will be implemented to ensure continuity in the event of staff absences or turnover. Management will continue to monitor compliance with federal reporting requirements and update internal controls as necessary.
Review individual grants for eligibility and documentation requirements • Create a policy to review the application for eligibility and ensure second approval on each application • Retain all documentation required by the grants
Review individual grants for eligibility and documentation requirements • Create a policy to review the application for eligibility and ensure second approval on each application • Retain all documentation required by the grants
Review and update Accounting Manual to align procedures with award requirements • Re-train employees on the proper timesheet procedures per the Accounting Manual • Perform monthly reconciliations of payroll allocations to grant budgets. • Require supervisory approval of timesheets prior to submissio...
Review and update Accounting Manual to align procedures with award requirements • Re-train employees on the proper timesheet procedures per the Accounting Manual • Perform monthly reconciliations of payroll allocations to grant budgets. • Require supervisory approval of timesheets prior to submission.
Review and update the Accounting Manual as needed • Re-train employees in the need for proper use of purchase orders, needed documentation to support charges to federal awards, and detailed receipts to show taxes paid (if any) according to the Accounting Manual
Review and update the Accounting Manual as needed • Re-train employees in the need for proper use of purchase orders, needed documentation to support charges to federal awards, and detailed receipts to show taxes paid (if any) according to the Accounting Manual
Review current policies regarding employee travel and expense reimbursements and adjust, if needed, to be aligned with award requirements • Implement a pre-approval process for all employee travel and expense reimbursements charged to federal programs. • Require detailed documentation (receipts, age...
Review current policies regarding employee travel and expense reimbursements and adjust, if needed, to be aligned with award requirements • Implement a pre-approval process for all employee travel and expense reimbursements charged to federal programs. • Require detailed documentation (receipts, agendas, purpose statements) to demonstrate direct program benefit. • Provide staff training on allowable costs and documentation standards.
Name of Auditee: City of Port Richey, Florida Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2024 CAP Prepared by: Adam Thompson, Finance Director Phone: (727) 835-1268 (4) Audit Finding 2024-004 - The City did not submit its ARPA annual report timel...
Name of Auditee: City of Port Richey, Florida Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2024 CAP Prepared by: Adam Thompson, Finance Director Phone: (727) 835-1268 (4) Audit Finding 2024-004 - The City did not submit its ARPA annual report timely. (a) Implementation Plan of Actions - Management will start compiling information required to complete this report immediately after March. (b) Implementation Date - This will be implemented for the year ended September 30, 2026. (c) Persons Responsible for Implementation - The Finance Director and the City Council.
Name of Auditee: City of Port Richey, Florida Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2024 CAP Prepared by: Adam Thompson, Finance Director Phone: (727) 835-1268 (3) Audit Finding 2024-003 - The City did not timely submit the Federal Data Coll...
Name of Auditee: City of Port Richey, Florida Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended September 30, 2024 CAP Prepared by: Adam Thompson, Finance Director Phone: (727) 835-1268 (3) Audit Finding 2024-003 - The City did not timely submit the Federal Data Collection Form to the appropriate authorities timely. (a) Implementation Plan of Actions - The City will reconcile significant asset and liability accounts at year-end and ensure there is supporting documentation. (b) Implementation Date - This will be implemented for the year ended September 30, 2026. (c) Persons Responsible for Implementation - The Finance Director and the City Council.
Management acknowledges this condition related to lack of adequate controls over the sliding fee discount program and is creating controls that will assure compliance with requirements.
Management acknowledges this condition related to lack of adequate controls over the sliding fee discount program and is creating controls that will assure compliance with requirements.
Assistance Listings number and program name: 21.027 COVID-19—Coronavirus State and Local Fiscal Recovery Funds Name of contact person: Heather Patel Completion date: October 31, 2025 Corrective Action Planned: Pinal County acknowledges the recommendations from the Arizona Auditor General and has imp...
Assistance Listings number and program name: 21.027 COVID-19—Coronavirus State and Local Fiscal Recovery Funds Name of contact person: Heather Patel Completion date: October 31, 2025 Corrective Action Planned: Pinal County acknowledges the recommendations from the Arizona Auditor General and has implemented procedures to ensure that the quarterly and annual reporting to the federal program aligns with the expenditures recorded in the county’s financial system. These procedures include: • Using the county’s general ledger to reconcile and match expenditures for the appropriate reporting period in accordance with GAAP. • Submitting the federal report to a manager or higher level for review and approval prior to sending to the federal agency. • Reviewing all expenditures, including those after year-end, to identify the appropriate reporting period. • Due to the timing of the annual report due date and the accrual period, there may be times when the annual report does not include accrued expenditures, as these expenditures may be recorded after the due date of the federal report. When this is the case, the county will make note of these expenditures and work with the federal agency to amend the annual report if needed.
The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.
The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.
Finding 2024-003: (Significant Deficiency) AL# 21.027: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury Condition: During testing of the quarterly CSLFRF Project and Expenditure Report submitted by the City for the period ending June 30, 2024, we noted that t...
Finding 2024-003: (Significant Deficiency) AL# 21.027: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury Condition: During testing of the quarterly CSLFRF Project and Expenditure Report submitted by the City for the period ending June 30, 2024, we noted that the revenue loss information and certain key line items were not reported accurately. Criteria or Specific Requirement: Per the U.S. Department of Treasury’s CSLFRF Compliance and Reporting Guidance, recipients are required to report revenue loss and key line item figures correctly in each required periodic Project and Expenditure Report and ensure all submitted information is complete, accurate, and supported by the City’s accounting records. Cause: The inaccurate reporting for revenue loss resulted from a misunderstanding of how the report portal worked. The City believed they were updating the total revenue loss amount to the correct balance. Review controls did not identify that the total revenue loss on the report got duplicated. The inaccurate reporting for key line items could not be fully determined. Effect: Submitting inaccurate reporting information increases the risk of potential noncompliance with Treasury reporting requirements. Corrective Plan: To address the underlying issues identified in the audit finding, the City will implement the following steps: 1. Review and Strengthen Reporting Process Implemented procedures to ensure reported amounts agree with supporting documentation and accounting records prior to submission. 2. Ensure Accurate Revenue Loss and Key Line Items Beginning with the 12/31/2025 reporting period, reconcile reported figures to portal calculations and confirm alignment with intended reporting period. 3. Add Additional Review Controls Incorporated checks to verify accuracy and completeness, prevent duplication of portal totals, and confirm figures match internal tracking records. These actions have been implemented and will continue to be monitored for compliance. Alex Fedak, CPA 1/7/26 Date Controller
Finding 2024-002: (Significant Deficiency) AL# 21.027: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury Condition: The City’s control procedures for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) requires the department personnel to authorize ...
Finding 2024-002: (Significant Deficiency) AL# 21.027: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury Condition: The City’s control procedures for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) requires the department personnel to authorize payment and the program manager to certify the expenditures to the CSLFRF program prior to being paid. The program manager did not approve four invoices prior to the expenditure being charged to the grant. Criteria or Specific Requirement: 2 CFR 200.303, the Non-Federal entity must establish and maintain effective internal controls over federal awards to ensure compliance with federal statutes, regulations and the terms and conditions of the awards. Cause: Purchase orders are created that identify projects that are part of the CSLFRF and expenditures coding is assigned at that time prior to the purchase. Once the invoice was approved by department personnel, the expenditures were applied to the assigned purchase order coding. Effect: Failure to follow established internal controls increases the risk of noncompliance with the grant requirements and processing unallowable costs towards the grant. Corrective Plan: To address the underlying issues identified in the audit finding, the City will implement the following steps: 1.Correct Approval Control GapInternal Audit worked with Accounts Payable and department personnel and made recommendations tocorrect the control gap and ensure compliance with approval procedures. It is anticipated theserecommendations will be implemented in the next two months. Additional review steps were added inaccounts payable to ensure required approvals obtained prior to payment processing. 2.Implement Monitoring ReportAccounting services developed a report to verify approvals and provide secondary oversight for CSLFRFexpenditures. These actions will be implemented and monitored to ensure compliance with grant requirements. Alex Fedak, CPA 1/7/26 Date Controller
Finding 2024-004: (Significant Deficiency) AL# 14.218: CDBG - Entitlement Grants Cluster, U.S. Department of Housing and Urban Development, all open grants and years Condition: During testing of the PR26 – CDBG Financial Summary report, it was identified that one payroll cycle was reported twice, re...
Finding 2024-004: (Significant Deficiency) AL# 14.218: CDBG - Entitlement Grants Cluster, U.S. Department of Housing and Urban Development, all open grants and years Condition: During testing of the PR26 – CDBG Financial Summary report, it was identified that one payroll cycle was reported twice, resulting in a duplication of payroll costs and an overstated reimbursement request. Criteria or Specific Requirement: 2 CFR 200.303(a) states that the City is required to establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Cause: The The ERP system conversion presented challenges to the City related to report development and in particular accuracy of the project management system. Effect: The reimbursement request was overstated, resulting in an excess draw of funds. This creates a risk of noncompliance with the grant requirements and potential repayment of funds. Corrective Plan: To address the underlying issues identified in the audit finding, the City will implement the following steps: 1.Coordinate with HUDResolve the duplicated payroll amount, including reimbursement or offset of the excess draw,in accordance with HUD guidance. 2.Reconcile Payroll Expenditures and DrawsPerform reconciliation of payroll-related expenditures and reimbursement draws for all HUDgrants for January 1–June 30, 2024, to ensure amounts claimed agree to general ledgeractivity. 3.Strengthen Recordkeeping and Reimbursement PracticesIn addition, the City will ensure that recordkeeping and reimbursement preparationpractices related to payroll expenses included in grant draw requests are sufficient tosupport amounts claimed and agree to general ledger activity.The Accounting Services Division will review existing departmental documentation practicesand communicate consistent expectations and best practices to promote accurate, complete,and supportable payroll draw requests.The City anticipates working with the department and having this process fully in place within3–4 months. These actions will be implemented and monitored to ensure compliance with grant requirements. Benjamin E Davis 1/7/26 Date Principal Planner Alex E Fedak 1/7/26 Date Controller
Finding 2024-003 Recommendations: The Director and the accounting department need to create procedures to ensure that both parties are reporting the same expenditures. Within the procedures created, there needs to be checks and balances to ensure that the recording is occurring before reporting figu...
Finding 2024-003 Recommendations: The Director and the accounting department need to create procedures to ensure that both parties are reporting the same expenditures. Within the procedures created, there needs to be checks and balances to ensure that the recording is occurring before reporting figures to the State. Action Taken: We agree with the recommendation. Our targeted implementation date is February 2025.
Finding: 2024-003 – Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended December 31, 2024 Condition: The Village failed to submit two of the quarterly reports in a timely manner. We consider this to be an instance of non-compliance...
Finding: 2024-003 – Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended December 31, 2024 Condition: The Village failed to submit two of the quarterly reports in a timely manner. We consider this to be an instance of non-compliance relating to the Reporting Compliance Requirement. Corrective Action Plan: The reports were delinquent due to the reporting compliance system. The finance department worked with the reporting compliance department to resolve the issue and the reports were then submitted. The Village will continue to work with the compliance department in the future if issues arise. Responsible Person for Corrective Action Plan: Donna M. Gayden, Interim CFO and the incoming CFO Implementation Date of Corrective Action Plan: January 1, 2026
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027; Passed through the Pennsylvania Department of State, Grant Period – Year Ended December 31, 2024. Recommendation: Management should implement a system of controls over reporting of federal funding. Views of R...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027; Passed through the Pennsylvania Department of State, Grant Period – Year Ended December 31, 2024. Recommendation: Management should implement a system of controls over reporting of federal funding. Views of Responsible Officials: Management agrees with finding. Planned Corrective Action: The District Manager will prepare and complete quarterly reports in a timely manner using District project expenses and salary and benefit information provided by the Sullivan County Business Manager. The District Manager is working with the District Fiscal Administrative Assistant on completing the reports; however, the District Manager has the responsibility of full review and approval. Persons Responsible: Carrie Richmond, District Manager Anticipation Completion Date: Immediately
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027; Passed through the Pennsylvania Department of State, Grant Period – Year Ended December 31, 2024. Recommendation: The District should apply the guidance in section 200.214 of the Uniform Guidance in determini...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027; Passed through the Pennsylvania Department of State, Grant Period – Year Ended December 31, 2024. Recommendation: The District should apply the guidance in section 200.214 of the Uniform Guidance in determining whether parties are excluded or ineligible for participation in Federal programs. Views of Responsible Officials: Management agrees with finding. Planned Corrective Action: For all future federal awards, the District will complete a disbarment search through SAM.gov applying the guidance in section 200.214 of the Uniform Guidance in determining whether parties are excluded or ineligible for participation in Federal programs. Persons Responsible: Carrie Richmond, District Manager Anticipation Completion Date: Immediately
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027; Passed through the Pennsylvania Department of State, Grant Period – Year Ended December 31, 2024. See Finding 2024-001 2024-001. SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Recommendation: Management should fo...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027; Passed through the Pennsylvania Department of State, Grant Period – Year Ended December 31, 2024. See Finding 2024-001 2024-001. SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Recommendation: Management should follow its policy and prepare the SEFA. Views of Responsible Officials: Management agrees with finding. Planned Corrective Action: The Business Manager has continued to track revenues and expenditures related to SEFA preparation in a more detailed manner and is learning how these figures are represented on the SEFA report. The Business Manager will be taking a formal class entitled “The Schedule of Expenditure of Federal Awards-SEFA” to become better equipped to complete the SEFA independently and in a timely manner. Persons responsible: Lynne Bassler, Business Manager Anticipation Completion Date: 5/31/2026
Management acknowledges the significant deficiency related to the preparation of the SEFA. To address this issue, management will enhance controls over preparing the SEFA and that the responsibility of verifying the federal nature of all awards and loans is designated to an appropriate finance team ...
Management acknowledges the significant deficiency related to the preparation of the SEFA. To address this issue, management will enhance controls over preparing the SEFA and that the responsibility of verifying the federal nature of all awards and loans is designated to an appropriate finance team member.
FA-2024-003 Strengthen Controls over Expenditures Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: AL Numbers and Title: Federal Award Number: Questioned Costs: Activities Allowed or Unallowed Allowable Cost/Cost Principles Significant...
FA-2024-003 Strengthen Controls over Expenditures Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: AL Numbers and Title: Federal Award Number: Questioned Costs: Activities Allowed or Unallowed Allowable Cost/Cost Principles Significant Deficiency Nonmaterial Noncompliance U.S. Department of Agriculture Georgia Department of Education 10.553 - School Breakfast Program 10.555 - National School Lunch Program COVID-19-10.555 - National School Lunch Program 245GA324N1199 (Year: 2024), 225GA324N1099 (Year:2024) $2,641.33 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating to ensure that expenditures were appropriately reviewed, approved, and documented. Corrective Action Plan: A bookkeeper has been hired for the School Nutrition Program. Bookkeeper keeps alphabetical organized files for each vendor to monitor and track revenue and expenditures. The bookkeeper prepares voucher packets for payments and credits for each vendor on a monthly basis. The bookkeeper signs the voucher package for accuracy. The Nutrition Director signs the voucher package for accuracy. Records are maintained under lock and key for a period of five years. Estimated Completion Date: July 1, 2025 Contact Person: Danny Durham, Director of School Nutrition Telephone:478-994-2031 Email: danny.durham@mcschools.org Title: Director of Financial Services
FA 2024-002 Strengthen Controls over Journal Entries Compliance Requirement: Activities Allowed or Unallowed Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Educati...
FA 2024-002 Strengthen Controls over Journal Entries Compliance Requirement: Activities Allowed or Unallowed Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education AL Numbers and Title: 10.553 – School Breakfast Program 10.555 – National School Lunch Program COVID-19-10.555 – National School Lunch Program Federal Award Number: 245GA324N1199 (Year: 2024), 225GA324N1099 (Year: 2024) Questioned Costs: Unknown Description: The policies and procedures of the School District were insufficient to ensure that journal entries made for the Child Nutrition Cluster were properly documented. Corrective Action Plan: All journal entries transferring cash from the School Nutrition Fund to the General fund will be done on a more frequent basis and include the detail of amounts used to arrive at the amount of the transfer. Estimated Completion Date: October 17, 2025 Contact Person: Danny Durham, Director of School Nutrition Telephone: 478-994-2031 Email: danny.durham@mcschools.org
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