Corrective Action Plans

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Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be c...
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be combined to identify students who were awarded the subsidized loan in error. These reports will be reviewed after each add/drop period. Management has made a request to our vendor to create a special report that will capture this data in a more time efficient manner. Person Responsible for Corrective Action Plan: Darla Hopper, VP of Enrollment Management Anticipated Date of Completion: 09/30/2025
Condition Friends of Family Health Center did not meet it financial reporting obligations under the grant during the year. Friends of Family Health Center did not file the Federal Financial Reporting ("FFR") by the due date. Response The late submission of FFR report was an overside due to staff sho...
Condition Friends of Family Health Center did not meet it financial reporting obligations under the grant during the year. Friends of Family Health Center did not file the Federal Financial Reporting ("FFR") by the due date. Response The late submission of FFR report was an overside due to staff shortage which has been resolved since then. We will do everything possible to avoid any late submission in the future. Responsible Party Dawn Ta, CFO Estimated Completion Date December 31, 2025
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selecte...
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selected for testing Friends of Family Health Center incorrectly applied the discount or were put in the incorrect category based on income and family size. Response One error in calculating a patient’s income with 40 others is a minor 2.5% error margin. FOFHC will have a quarterly training course on how to properly use the various income level tables provided to the front office staff. Responsible Party Dawn Ta, CFO Estimated Completion Date December 31, 2025
2024-005 REPORTING REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material weakness in internal controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context...
2024-005 REPORTING REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material weakness in internal controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context: Documentation was not provided to support the number of federally connected students reported on the Impact Aid application. Corrective Action: The District will establish a process to ensure proper documentation is maintained to support the Impact Aid application. Planned completion date for corrective action plan: For the period ending August 31, 2025. Name of the contact person responsible for corrective action: Laticia John, Business Coordinator
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all ...
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all vendors working on projects funded by federal grant dollars.
Finding 574638 (2024-005)
Material Weakness 2024
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will ha...
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2025
Finding 574637 (2024-004)
Material Weakness 2024
FINDING 2024-004 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately, which will include ...
FINDING 2024-004 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately, which will include implementing a federal procurement policy. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Anticipated Completion Date: August 30, 2025
Finding 574636 (2024-003)
Material Weakness 2024
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Depa...
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Department head will review and document their review for all Federal Grant disbursements for applicable grant requirements and Federal regulations. Anticipated Completion Date: August 30, 2025
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: The AHA Director of Assisted Housing and the Senior Housing Inspector are conducting monthly reviews of inspection reports to identify deficiencies and ensure inspections extensions are completed on time. This program management process will continue on an ongoing basis. Additionally, we have hired an additional inspector to help meet inspection deadlines and improve overall timeliness. Anticipated Completion Date: Ongoing
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing
Margaret McCowen The NMBHPA Executive Director and Board Treasurer will annually review all audit requirements to ensure compliance with 200 CFR Subpart F. This review will take place during the annual budget preparation process for the upcoming fiscal year and responsibility for meeting the require...
Margaret McCowen The NMBHPA Executive Director and Board Treasurer will annually review all audit requirements to ensure compliance with 200 CFR Subpart F. This review will take place during the annual budget preparation process for the upcoming fiscal year and responsibility for meeting the requirements will be assigned as a performance goal to the Executive Director
Margaret McCowen: time sheet errors and discrepancies: We will review the existing time sheet policy with the Board Treasurer, and modify the policy for Board approval to include the correct internal control procedure. After the Board approval, we will schedule a mandatory training meeting with all...
Margaret McCowen: time sheet errors and discrepancies: We will review the existing time sheet policy with the Board Treasurer, and modify the policy for Board approval to include the correct internal control procedure. After the Board approval, we will schedule a mandatory training meeting with all timesheet staff to be held annually. Unsigned employment agreements: We will review the existing employment agreement policy to confirm that storage and maintenance instruction are included. We will submit the revised policy to the Board of Directors for approval and when approved, will send a copy to all hiring employees (Board president, Vice-president, Secretary and Treasurer, Executive Director). The policy will require maintenance in an electronic file and also in a paper file to be maintained by the Board President.
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, fami...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, families, and employees. We are committed to safeguarding sensitive data as part of our responsibility to operate with integrity and stewardship. To address these findings, SCU is working closely with our IT specialist in taking the following steps: a. Information Security Program: we are formalizing a written information security plan that meets the GLBA requirements, including risk assessment, safeguards, and monitoring. b. Designation of Coordinator: A qualified staff member has been designated to oversee GLBA compliance and ensure accountability in implementing safeguards. c. Employee training: Faculty and staff will be trained on data privacy, cybersecurity practices, and proper handling of sensitive information. d. Technical Safeguards: We will be enhancing systems for data encryption, access controls, and monitoring to reduce risks related to unauthorized access or disclosure. e. Ongoing review: Regular testing, audits, and updates will be conducted to ensure continuous improvement and adherence to GLBA standards. At Southwestern Christian University, we believe in protecting the personal information of our students and families is part of our mission of stewardship. Just as we are called to be faithful with financial resources, we are equally called to be trustworthy in safeguarding data. We are confident that the corrective actions being implemented will ensure that SCU not only meets compliance standards but also reflects our values of integrity, accountability and care. Person Responsible for Corrective Action Plan: Mark Arthur, Chief Financial Officer Anticipated Date of Completion: June 30, 2026
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bo...
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Compliance Requirement: Special Tests and Provisions – Residual Receipts Funds Supportive Housing for the Elderly (Section 202), Assistance Listing 14.157 Recommendation: Every effort should be made to comply with the residual receipts requirement to make deposits into the account within 60 days following the end of the fiscal year or request waivers by the due date. Planned Corrective Actions: Every effort will be made to deposit the required amount within the allotted 60 day period. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100. Sincerely, MBDM – Drake Senior Housing Corporation Elizabeth Goleski, CEO
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: ...
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Compliance Requirement: Special Tests and Provisions – Residual Receipts Funds Supportive Housing for the Elderly (Section 202), Assistance Listing 14.157 Recommendation: Every effort should be made to comply with the residual receipts requirement to make deposits into the account within 60 days following the end of the fiscal year or request waivers by the due date. Planned Corrective Actions: Every effort will be made to deposit the required amount within the allotted 60 day period. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100. Sincerely, MBDM – Epsilon Senior Housing Corporation Elizabeth Goleski, CEO
The Commission will implement procedures to ensure compliance with the Unjiorm Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 2 CFR 200.3 18 and CFR 200.320 and the Code ofAlabama 1975, Title 39.
The Commission will implement procedures to ensure compliance with the Unjiorm Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 2 CFR 200.3 18 and CFR 200.320 and the Code ofAlabama 1975, Title 39.
View Audit 364869 Questioned Costs: $1
FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Suspension and Debarment Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Official...
FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Suspension and Debarment Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office implemented a contract to cover all suspension and debarment. This contract procedure was put in place in 2024 but was not implemented on all invoices over $25.000. It was believed to only be needed in instances where an invoice was not present. We will now have a contract for all vendors receiving payments over $25,000. Anticipated Completion Date: Completion is anticipated 12-31-2025.
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur wi...
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will collect dual signatures on all submissions for reporting requirements. The Auditor’s Office will also have additional employees verify submissions to ledgers for accuracy. Anticipated Completion Date: Completion is anticipated for all reports due after 12-31-2025.
FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late...
FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late in the case of the 2024 grant. Plan: Management will monitor grant expenditure reports closely and will improve their control activities to ensure that grant performance reports are filed as required by the grant agreement. Anticipated Date of Completion: As soon as possible – before FY26 year end Name of Contact Person: Mary Ventrella, CPA - Finance Director Management Response: Since the audit, we have evaluated our monitoring procedures and control activities to ensure that grant expenditure reports are readily available and grant performance reports are filed timely.
Audit Finding 2024-001 The corrective action will be followed up by agency Executive Director (ED), Tracy Diaz and Board of Directors Executive Committee, Laura Burrowes, Steven Stanley and Robin Haidle, along with the assistance of the entire Board of Director s (BOD). CAPNM has attempted to have a...
Audit Finding 2024-001 The corrective action will be followed up by agency Executive Director (ED), Tracy Diaz and Board of Directors Executive Committee, Laura Burrowes, Steven Stanley and Robin Haidle, along with the assistance of the entire Board of Director s (BOD). CAPNM has attempted to have a County Commissioner serve on our BOD and over the last several years they have refused. Due to this we have once again reached out to Columbia Falls, Whitefish, and Kalispell City Council members to seek representation on our board. Recently, we had a response from a Kalispell City Council member. Ryan Hunter was approved and elected to the CAPNM Board of Directors on August 21, 2025, his term began immediately. Therefore, this finding has now been resolved.
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.
2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being ...
2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being sought. A Procurement policy has been obtained from another county to review. It is the intent of the county to prepare its own "Procurement Policy" during a policy work session, coming up this fall. Treasurer Anderson and Clerk Freese also toll a 2-day Procurement training put on by the Federal Grants Training Program this summer. In the meantime, the county will continue to follow all federal regulations for every grant we receive as per each particular project dictates.
Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to as...
Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to assist with audit preparation. This was in addition to $30,000 set aside in the county treasurer's budget for audit consulting. The county commissioners hired an individual in September 2024. That individual left employement with the county in November 2024 and the position was not refilled through the end of fiscal year 2025. The remainder of the FY2024 audit preparation was completed in-house. Due to reductions in revenue and budget constraints, both the $100,000 allocation for a new employee and the $30,000 for consulting services were cut from the commissioners' and treasurer's budgets, so the county is pivoting on audit preparation resposibilities and expanding the number of in-house employees working on different facets of the preparation. With the exception of the CPA that was on staff for two months, the rest of the finance staff has been stable for at least two years and have grown in their knowledge of county finances. We are utilizing 6-7 different staff members on parallel tasks with oversight and assistance from the county treasurer and clerk. We are confident that the audit preparation for FY2025 will be completed months earlier such that trial balances and supporting documentation will be available to our auditors in time to meet the federal submission deadline.
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
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