Corrective Action Plans

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Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education...
Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education Assistance Group to provide a comprehensive business process review of its financial aid operations. The objective of this review is to improve upon the functionality of processes, internal controls, and systems to ensure regulatory compliance and the effectiveness of service deliverables to students receiving financial aid. This review will include updates to policies, procedures, and internal controls for the import and export of electronic records, document tracking and file review, packaging and awarding, satisfactory academic progress, disbursement and reconciliation, withdrawal and Return to Title IV. Workflow and gap analysis will be performed to ensure intraoffice Title IV program compliance and best practices. Second, the institution has entered into a professional services agreement with Higher Education Assistance Group to provide interim staffing and third-party federal student aid processing including, but not limited to, counseling students and families on financial aid options, assisting with the management of Federal Direct Loan and Federal Graduate PLUS Loan programs to include student eligibility, file review, awarding, and origination and disbursement authorization using Populi, COD and other Department of Education software. In addition, Higher Education Assistance Group will provide additional Title IV training for personnel involved in federal student aid processing. With more than 35 years of experience, Higher Education Assistance Group and its team of seasoned consultants, all of whom have worked in federal student aid administration, whether in public/private colleges and universities or for the Department of Education itself, specializes in the compliant administration of Title IV student financial aid programs. The institution will adopt a supplemental internal control to cross-check student eligibility for Direct PLUS loans to ensure that an over-award is not originated and disbursed. Anticipated completion date: November 15, 2025
View Audit 370654 Questioned Costs: $1
Auditors noted that for two of the six sampled students, funds were returned to ED more than 45 days after the date the University determined the student had withdrawn. For one selection, a Return of Title IV calculation was performed timely, but an administrative error caused the disbursement to be...
Auditors noted that for two of the six sampled students, funds were returned to ED more than 45 days after the date the University determined the student had withdrawn. For one selection, a Return of Title IV calculation was performed timely, but an administrative error caused the disbursement to be delayed eight months. For the second selection, the University was notified of withdrawal in early March 2025 and student was included in registrar’s withdrawal listing, but was missed in review by Student Financial Services until late April 2025. Contact Person(s): Vickie Rekov, VP Enrollment Services; Roger Wilson, Associate Director of Financial Aid, SFS; Ryan Porter, CFO and Bernie Rundquist, Controller Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: All employees in Student Financial Services and Accounting Office involved in the reporting, distribution, drawdown and return of federal funds have reviewed the criteria under 34 CFR 668.22 The two departments involved will be meeting in the month of September 2025 to review policies and procedures to ensure controls exist and are well documented to ensure funds are returned timely. In-charge personnel will gather training resources to educate those involved in the reporting, disbursement and return of Title IV Funds. Anticipated completion date: October 2025
The University drew down $72,265 in Federal Supplemental Educational Opportunity Grants (FSEOG) funds in October 2024 and disbursed funds to students through January 2025. No amounts were disbursed to students within the required three business days from receipt of funds, and no funds were returned ...
The University drew down $72,265 in Federal Supplemental Educational Opportunity Grants (FSEOG) funds in October 2024 and disbursed funds to students through January 2025. No amounts were disbursed to students within the required three business days from receipt of funds, and no funds were returned to ED. Contact Person(s): Vickie Rekov, VP Enrollment Services; Cynthia Kennedy, Director of SFS; Ryan Porter, CFO and Bernie Rundquist, Controller Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: All employees in Student Financial Services and Accounting Office involved in the reporting, distbursement and drawdown of federal funds have reviewed the criteria under 34 CFR 668.162 under the advance payment method. The two departments involved will be meeting in the month of September 2025 to review current process and procedures and make appropriate changes to meet these requirements. Anticipated completion date: September 30, 2025
View Audit 370626 Questioned Costs: $1
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs they failed to maintain the property. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response Management is working with HUD to ensure all exigent h...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs they failed to maintain the property. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response Management is working with HUD to ensure all exigent health and safety issues are resolved by the completion date above. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entere...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entered into a purchase and sale agreement with The Christ Hospital to acquire the property for $1,485,528. Pending HUD approval. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar
View Audit 370591 Questioned Costs: $1
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entere...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entered into a purchase and sale agreement with The Christ Hospital to acquire the property for $1,485,528. Pending HUD approval. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar
View Audit 370591 Questioned Costs: $1
Finding 2025-001: Material Weakness in Internal Control over Financial Reporting ● Condition: The Abbey did not consolidate subsidiaries in its financial statements. ● Criteria: Generally Accepted Accounting Principles (GAAP) require that all subsidiaries be consolidated into the parent Abbey's fina...
Finding 2025-001: Material Weakness in Internal Control over Financial Reporting ● Condition: The Abbey did not consolidate subsidiaries in its financial statements. ● Criteria: Generally Accepted Accounting Principles (GAAP) require that all subsidiaries be consolidated into the parent Abbey's financial statements. ● Cause: The Abbey lacked adequate internal controls to ensure all subsidiaries were identified and consolidated. ● Effect: The financial statements were materially misstated, as they did not include the financial position and results of operations of the subsidiary. Corrective Action Plan: ● Responsible Person: Right Reverend Gregory Boquet, O.S.B. ● Planned Action: We agree with the auditor’s finding that there is a material weakness in internal control over financial reporting due to the non-consolidation of subsidiaries. However, after careful consideration, management has decided not to implement the recommended procedures to consolidate the subsidiaries. ● Justification: Management believes that the current procedures are adequate, and that the non-consolidation of the subsidiaries does not materially affect the financial statements. The costs and resources required to implement the recommended procedures outweigh the benefits, given the subsidiaries’ minimal impact on the overall financial position and results of operations. We will continue to monitor the situation and reassess it if necessary. ● Anticipated Completion Date: Not applicable, as no changes will be made. Views of Responsible Officials: The Abbey disagrees with the finding. Management believes that the current procedures are adequate, and that the non-consolidation of the subsidiaries does not materially affect the financial statements. The Abbey will not implement the recommended procedures but will continue to monitor the situation and reassess if necessary.
Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility req...
Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility requirements.
Replacement Reserve Deposits: Comments on Finding and Recommendation - The Corporation acknowledges that sufficient deposits were not made due to the outstanding subsidies not received until the fiscal year 2026; Actions Taken or Planned - The Corporation made the deficient required reserve deposits...
Replacement Reserve Deposits: Comments on Finding and Recommendation - The Corporation acknowledges that sufficient deposits were not made due to the outstanding subsidies not received until the fiscal year 2026; Actions Taken or Planned - The Corporation made the deficient required reserve deposits once the outstanding subsidies were received in fiscal year 2026
The Village will approve a policy to cover any and all contractors awarded contracts which federal funds or grants will be received.
The Village will approve a policy to cover any and all contractors awarded contracts which federal funds or grants will be received.
Finding: 2025-001: Procurement Noncompliance - Child Nutrition Cluster. Contact Person: Lisa Hammerly, Director of Business Services. Recommendation: The District should continue to implement and monitor updated procurement procedures, including use of centralized tracking, pre-approval of purchases...
Finding: 2025-001: Procurement Noncompliance - Child Nutrition Cluster. Contact Person: Lisa Hammerly, Director of Business Services. Recommendation: The District should continue to implement and monitor updated procurement procedures, including use of centralized tracking, pre-approval of purchases, and adherence to formal solicitation processes. Corrective Action: The District agrees with the finding. Corrective action was initiated in April 2025, including adoption of revised procurement procedures, implementation of monitored tracking, and initiation of a formal bid process for recurring food purchases. Proposed Completion Date: Policy revision completed March 2025, staff training completed April 2025, monthly monitoring effective beginning May 2025.
The Office of the University Registrar and the Office of the Law Registrar have reviewed current policies and procedures related to the reporting of status changes in NSLDS. The Office of the Law Registrar will report status changes to National Student Clearinghouse no later than 30 days after degre...
The Office of the University Registrar and the Office of the Law Registrar have reviewed current policies and procedures related to the reporting of status changes in NSLDS. The Office of the Law Registrar will report status changes to National Student Clearinghouse no later than 30 days after degree conferral but no later than June 30. In additional they will follow up with NSC three business days after submission to verify that the file was received and processed correctly. The Law School does not confer degrees year-round. Based on the ABA accreditation and program plan, Fowler School of Law has three conferral dates: January 31, June 10, and September 1. Most students are conferred on June 10. The Office of the University Registrar will report enrollment status changes to the National Student Clearinghouse every 30 days. Unlike the Law school, the University Registrar’s office confers degree year-round. The registrar’s office is scheduled to submit a Degree Verify file every two weeks to the clearinghouse and will review students in submited degree file for accuracy in our reporting.
Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration...
Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration:  Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy.  Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation:  All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application.  Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS).  The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year.  Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls:  Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors.  Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025
The Project will deposit, on a monthly basis, the required amount per the CAP Regulatory Agreement. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will deposit, on a monthly basis, the required amount per the CAP Regulatory Agreement. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will strengthen controls over record keeping and maintaining tenant files with an increased emphasis on timely and appropriately documenting all compliance requirements of HUD. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will strengthen controls over record keeping and maintaining tenant files with an increased emphasis on timely and appropriately documenting all compliance requirements of HUD. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will strengthen controls over record keeping and maintaining tenant files with an increased emphasis on timely and appropriately documenting all compliance requirements of HUD. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will strengthen controls over record keeping and maintaining tenant files with an increased emphasis on timely and appropriately documenting all compliance requirements of HUD. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will deposit, on a monthly basis, the required amount per the CAP Regulatory Agreement. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will deposit, on a monthly basis, the required amount per the CAP Regulatory Agreement. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will strengthen controls over record keeping and maintaining tenant files with an increased emphasis on timely and appropriately documenting all compliance requirements of HUD. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will strengthen controls over record keeping and maintaining tenant files with an increased emphasis on timely and appropriately documenting all compliance requirements of HUD. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
The Project will obtain banking accounts that do not assess monthly charges. The Project will also monitor the account to ensure that the security deposit account at all times equals or exceeds the aggregate of all outstanding obligations to tenants for refundable security deposits. Contact: Adrienn...
The Project will obtain banking accounts that do not assess monthly charges. The Project will also monitor the account to ensure that the security deposit account at all times equals or exceeds the aggregate of all outstanding obligations to tenants for refundable security deposits. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended February 28, 2025. Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Rental and Cooperative Housing (Section 221(d)(4)) Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will ensure that the accounts reconcile to source documents as part of our month-end closing process. Anticipated Completion Date August 31, 2025
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. ...
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. Anticipated Completion Date July 31, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-006 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will ensure that our work order system is followed. Anticipated Completion Date September 30, 2025
Finding 2025-006 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will ensure that our work order system is followed. Anticipated Completion Date September 30, 2025
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completio...
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completion Date July 1, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-004 Compliance Requirements E – Eligibility Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow procedures to ensure tenant eligibility and will review the accuracy and completeness of the documentation in tenant f...
Finding 2025-004 Compliance Requirements E – Eligibility Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow procedures to ensure tenant eligibility and will review the accuracy and completeness of the documentation in tenant files on a periodic basis. Anticipated Completion Date September 30, 2025
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