Corrective Action Plans

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Finding: 2025-002 Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this audit finding. In July 2025, a comprehensive recertification work plan was implemented to strengthen procedures and improve tracking of pending PLA recertifica...
Finding: 2025-002 Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this audit finding. In July 2025, a comprehensive recertification work plan was implemented to strengthen procedures and improve tracking of pending PLA recertifications. Case workers are provided with monthly calendars to guide required activities and are assigned individual spreadsheets identifying their pending cases each month. Each spreadsheet includes a defined number of cases to be completed daily. PLA Supervisor and the Program Manager monitor progress monthly and provide feedback to staff as appropriate. Additionally, designated days each month are reserved for case workers to follow up on pending DHB-5097s to ensure timely action is taken and to prevent cases from continuing to extend from month to month. Proposed Completion Date: Immediate and ongoing.
Finding: 2025-001 Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: The cases identified with missing forms originated during the COVID-19 pandemic, when differing guidance was issued by Child Welfare and Medicaid DHHS. During this time, Medicaid staff wer...
Finding: 2025-001 Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: The cases identified with missing forms originated during the COVID-19 pandemic, when differing guidance was issued by Child Welfare and Medicaid DHHS. During this time, Medicaid staff were informed that reviews were not required. The Medicaid worker had previously been responsible for tracking due dates and notifying staff; however, because the reviews were deemed unnecessary during the pandemic, these cases were not included on the tracking report. To prevent this issue from occurring in the future, a new process has been developed and implemented collaboratively between Permanency Planning and Medicaid to track 5120a forms. Effective August 2025, The Human Services Coordinator now provides a spreadsheet at least monthly identifying 5120a forms that are due and their respective due dates. This spreadsheet is shared with Medicaid staff and the Child Welfare team for completion, and supervisors are responsible for ensuring timely completion of the forms. Management will strengthen internal controls by implementing several measures to ensure all required eligibility documentation is properly completed and maintained. A standardized eligibility documentation checklist will be introduced for all foster care and adoption assistance cases to clearly identify required forms, including initial and annual Form 5120a recertifications, with supervisors verifying completion during routine case reviews. Supervisory oversight will be enhanced through quarterly CQI random casefile audits focused specifically on documentation accuracy and timeliness, with results used to address trends or additional support needs. In addition, all applicable staff will receive refresher training on federal documentation requirements, correct completion and filing of Form 5120a, and required recertification timelines, and this guidance will also be incorporated into onboarding for new employees. Proposed Completion Date: Immediate and ongoing.
Name of contact person: Pamela Midgett, AMA IMS II and Julie Shreckengast, FCMA IMS II Corrective Action: Perquimans County Department of Social Services unit will continue to 2nd party cases monthly, randomly review workers’ online data and continue to train on the importance of pulling current and...
Name of contact person: Pamela Midgett, AMA IMS II and Julie Shreckengast, FCMA IMS II Corrective Action: Perquimans County Department of Social Services unit will continue to 2nd party cases monthly, randomly review workers’ online data and continue to train on the importance of pulling current and accurate information from the online data system. IMS Midgett and Shreckengast will continue to emphasize the importance of the checklist on review forms and applications to ensure proper verification of information and documentation. IMS Midgett and Shreckengast will implement a Joint Unit Meeting for remedial training that includes proper documentation for Income / Resources / Household Composition. Corrective Action: Perquimans County Department of Social Services unit will continue to 2nd party cases monthly, randomly review workers’ calculations and procedures of the countable income and resources. IMS will implement a training with question and answer session regarding proper budgeting income and calculation of resources. Corrective Action: Perquimans County Department of Social Services unit will continue to 2nd party cases monthly, randomly review workers calculations and procedures of the countable income. Training on proper use of Request For Information, DHB-5097 and additional training on State Residency verification. Proposed Completion Date: Joint Unit Training to be conducted at the February 2026 unit meeting for the entire Medicaid unit.
Corrective Action Planned: Due to the Commission’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Commission has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Corrective Action Planned: Due to the Commission’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Commission has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City design controls to ensure an adequate review process is in place to review potential contractors to verify they are not suspended or debarred prior to entering into transactions wi...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City design controls to ensure an adequate review process is in place to review potential contractors to verify they are not suspended or debarred prior to entering into transactions with contractors. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding. Lake Havasu City recognizes the need for strengthened internal communication and training related to federal grant requirements, specifically in identifying purchases made with federal funds. To address this, the City is implementing the following actions: • Providing targeted training to all departments that utilize federal grant funding, emphasizing requirements under Assistance Listing 21.027, including pre-procurement responsibilities such as identifying grant-funded purchases. • Reinforcing procedures requiring departments to clearly flag and communicate any purchases involving federal funds to Procurement before initiating vendor engagement. • Updating internal guidance and distributing a quick-reference tool that outlines federal procurement obligations so that staff can easily determine when suspension and debarment checks are required. • Conducting follow-up training and monitoring to ensure departments consistently follow notification and documentation procedures. These steps will help ensure federal requirements are met and that Procurement is appropriately informed to perform suspension and debarment checks before transactions occur. Name(s) of the contact person(s) responsible for corrective action: Vijette Saari, Grants Manager Trinna Ware, Finance Division Manager Planned completion date for corrective action: June 30, 2026 If the U.S. Department of Treasury has questions regarding this plan, please call Trinna Ware at (928)854-0735.
The District will impose a system of checks and balances among the Superintendent, Treasurer and Encumbrance Clerk to ensure that the proper codes are input in the financial software to correctly track Federal revenues and expenditures. Monthly reports will be run and cross-checked by District accou...
The District will impose a system of checks and balances among the Superintendent, Treasurer and Encumbrance Clerk to ensure that the proper codes are input in the financial software to correctly track Federal revenues and expenditures. Monthly reports will be run and cross-checked by District accounting personnel and the Superintendent. These actions will be completed immediately or no later than January 14, 2026 to ensure proper coding of Federal revenues and expenditures.
The District Superintendent will immediately train the District's accounts payable department on the requirements of the Davis-Bacon Act. Furthermore, the District Superintendent will be the point of contact for construction projects that are funded with Federal funds. They will ensure that any cont...
The District Superintendent will immediately train the District's accounts payable department on the requirements of the Davis-Bacon Act. Furthermore, the District Superintendent will be the point of contact for construction projects that are funded with Federal funds. They will ensure that any contract entered into must include the locally prevailing wage to be paid to workers including fringe benefits. The Superintendent will require contractors to pay covered workers weekly and sumbmit weekly certified payrolls to the accounts payable personnel. Also, the District Superintendent will inspect the job site to ensure that Davis-Bacon wage determination and posters are displayed at the site. These actions will be completed immediately or no later than January 14, 2026 to ensure the proper District personnel are trained and understand the requirements for future construction projects that are Federally funded and are required to follow the Davis-Bacon Act.
Management will implement a process to ensure all required documentation is maintained on file.
Management will implement a process to ensure all required documentation is maintained on file.
The District will strengthen controls to ensure all service contracts, including those charged to federal programs, are approved by the Board of Education and entered into the official minutes prior to execution and payment, in accordance with 2 C.F.R. § 200.318(a), state law, and District policy. E...
The District will strengthen controls to ensure all service contracts, including those charged to federal programs, are approved by the Board of Education and entered into the official minutes prior to execution and payment, in accordance with 2 C.F.R. § 200.318(a), state law, and District policy. Effective immediately, all service contracts will be submitted for Board approval before services begin. No contract will be executed and no purchase order will be issued without documented Board approval. Accounts payale will verify Board approval prior to processing payment. Procurement personnel and Federal program staff will receive training on Uniform Guidance procurement requirements, including suspension and debarment procedures. The Business Manager will perform reviews on Federal program expenditures to ensure ongoing compliance. The District believes these measures will correct the defiency and prevent recurrence.
Marshall Municipal Utilities respectfully submits the following Corrective Action Plan for the year ended September 30, 2025. Contact information for the individual responsible for the corrective action: Aimee Klinge, Finance Officer City of Marshall, Missouri Independent Public Accounting Firm: Ger...
Marshall Municipal Utilities respectfully submits the following Corrective Action Plan for the year ended September 30, 2025. Contact information for the individual responsible for the corrective action: Aimee Klinge, Finance Officer City of Marshall, Missouri Independent Public Accounting Firm: Gerding, Korte & Chitwood, P.C., 723 Main Street, Boonville, MO 65233 Audit Period: Year ended September 30, 2025 The findings from the September 30, 2025, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Significant Deficiency 2025-001 Uniform Guidance Audit Submission Recommendation: The City should submit its single audit reporting package to the federal audit clearinghouse no later than 9 months after fiscal year-end. Action Taken: Marshall Municipal Utilities will implement procedures to ensure timely submission of the Single Audit reporting package. MMU will work with auditors to track all federal reporting deadlines, and responsibility for monitoring and submitting the report is assigned to the Controller. Management will monitor the audit timeline to ensure submission occurs within the required nine-month deadline.
Completion Date: September 30, 2026
Completion Date: September 30, 2026
Sincerely, Tony Bersano, Controller, Marshall Municipal Utilities
Sincerely, Tony Bersano, Controller, Marshall Municipal Utilities
Finding 2025-002: Significant Deficiency in Internal Control over Compliance – Allowable Costs Corrective Action Plan: With the implementation of the new UKG Payroll system in January 2026, the timesheet process now systematically reflects the ability for individuals to track time spent on individua...
Finding 2025-002: Significant Deficiency in Internal Control over Compliance – Allowable Costs Corrective Action Plan: With the implementation of the new UKG Payroll system in January 2026, the timesheet process now systematically reflects the ability for individuals to track time spent on individual grants when completing their timesheet. Name of Person Responsible for the Corrective Action Plan: Francene LaPoint, Chief Financial Officer and Brandon Wheatly, University Controller Anticipated Completion Date: January 30, 2026
Student Financial Assistance Cluster – 84.063 – Federal Pell Program Recommendation: We recommend the University should return the overawarded amount of $924 to the US Department of Education and should review and strengthen internal controls over Pell Grant calculations and disbursements to prevent...
Student Financial Assistance Cluster – 84.063 – Federal Pell Program Recommendation: We recommend the University should return the overawarded amount of $924 to the US Department of Education and should review and strengthen internal controls over Pell Grant calculations and disbursements to prevent future over-awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The institution will implement a recurring enrollment report for Pell-eligible students reflecting enrollment term and registered credits as of the date the report is run. The report will be reviewed weekly during summer terms and after census for fall and spring to identify enrollment changes impacting Pell eligibility. Names of the contact persons responsible for corrective action: Lauren Svanda, Director of Financial Aid Planned completion date for corrective action plan: 05/04/2026
2025-001 Federal Ward Findings and Questioned Costs Material Noncompliance/Material Weakness ALN: 14.872 Public Housing Capital Fund Finding summary: The Authority recorded unearned revenue related to the Capital Fund drawdowns for operations on the Central Office Cost Center. This amount should hav...
2025-001 Federal Ward Findings and Questioned Costs Material Noncompliance/Material Weakness ALN: 14.872 Public Housing Capital Fund Finding summary: The Authority recorded unearned revenue related to the Capital Fund drawdowns for operations on the Central Office Cost Center. This amount should have been reflected as revenue on the public housing programs. Statement of Concurrence: The Authority agrees with the finding. Corrective Action Plan: The Authority did not spend capital fund draw downs on the COCC program. The Authority’s practice was to record drawdowns as deferred revenue on COCC until they were spent and at that time moved the expenditures to the public housing programs. Going forward the Authority will record the drawdowns as revenue for the public housing programs when they are drawn down. Effective immediately, the Comptroller, Jennifer Yager, will implement this policy. Jennifer can be reached at 203-596-2640 and Jennifer.yager@waterburyha.org.
Management Response: All staff will be required to complete annual trainings during the same time each year. This has already been implemented for the current fiscal year FY25-26. Tracking of staff trainings will be maintained monthly and filed in staff personnel files by a Human Resources staff.
Management Response: All staff will be required to complete annual trainings during the same time each year. This has already been implemented for the current fiscal year FY25-26. Tracking of staff trainings will be maintained monthly and filed in staff personnel files by a Human Resources staff.
Management has implemented enhanced monitoring procedures, including assigning responsibility for validating the final Single Audit submission within the required deadlines, to ensure all required steps are completed timely in future periods. Mark Tighe, Director of Accounting, was responsible for t...
Management has implemented enhanced monitoring procedures, including assigning responsibility for validating the final Single Audit submission within the required deadlines, to ensure all required steps are completed timely in future periods. Mark Tighe, Director of Accounting, was responsible for the implementation of this corrective action plan. This corrective action plan has been fully implemented as of March 16, 2026.
Information on the federal program: Subject: Education Stabilization Fund (ESF) Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Federal Award Numbers and Years (Or Other Identifying Numbers): S425U210013, S4...
Information on the federal program: Subject: Education Stabilization Fund (ESF) Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Federal Award Numbers and Years (Or Other Identifying Numbers): S425U210013, S425W210015 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Equipment and Real Property Management Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirements. Context: There were nine equipment purchases made during the audit period and charged to the ESF grants which totaled $564,248 in the aggregate. During testing of equipment purchases, the following items were noted: • The School Corporation provided a capital asset listing that had not been updated since 2020. As a result, none of the equipment items selected for testing that were purchased with ESF funds were included on the listing. Additionally, the listing did not include required elements under 2 CFR §200.313(d), including documentation of the federal funding source and the condition of the property. • The School Corporation did not perform a physical inventory of equipment at least once every two years as required by 2 CFR §200.313(d)(2). As such, management was unable to demonstrate that federally funded equipment was being periodically verified and reconciled to property records. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will perform a comprehensive inventory and evaluation of all assets including those purchased with ESF funds and ensure they are appropriately recorded within a detailed asset listing. Responsible Party and Timeline for Completion: Philip Marsh / Jun 30, 2026
Information on the federal program: Subject: Special Education Cluster (IDEA) – Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Cluster Assistance Listing Number: 84.027 Federal Award Numbers and Years (Or Other Identifying Numbers): H027A230084, H...
Information on the federal program: Subject: Special Education Cluster (IDEA) – Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Cluster Assistance Listing Number: 84.027 Federal Award Numbers and Years (Or Other Identifying Numbers): H027A230084, H027A240084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Suspension and Debarment Audit Findings: Significant Deficiency Condition: An effective system of internal controls was not in place at the School Corporation to ensure the School Corporation’s compliance with applicable requirements related to the Special Education Cluster (IDEA), specifically with respect to Suspension and Debarment requirements. No instances of noncompliance (entering a contract with a vendor that was suspended or debarred) were identified in the transactions selected for testing. The matter represents a deficiency in internal controls over the Suspension and Debarment process, rather than identified noncompliance with program requirements. Context: Suspension and Debarment As part of its internal control procedures, the School Corporation utilizes the System for Award Management (SAM.gov) to verify the eligibility status of vendors prior to engaging in financial transactions. This verification process is designed to ensure that vendors are not suspended, debarred, or otherwise excluded from participation in federal programs, in accordance with applicable procurement regulations. Two covered transactions that equaled or exceeded $25,000 were identified. Each of the identified transactions were selected for testing, totaling $73,208. The School Corporation did not verify the vendors' suspension and debarment status prior to payment for each of the covered transactions. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will enhance controls and review processes surrounding Procurement, Suspension and Debarment under Special Education funds to ensure all compliance requirements of the program are met. Responsible Party and Timeline for Completion: Philip Marsh / Mar 31, 2026
Grant Funds Spent After Award Ended The Division will complete the following corrective actions: •Continue cross-divisional meetings to strengthen grant oversight and fiscal monitoring. •Complete targeted training to support consistent application of requirements. •Update policies and procedures to ...
Grant Funds Spent After Award Ended The Division will complete the following corrective actions: •Continue cross-divisional meetings to strengthen grant oversight and fiscal monitoring. •Complete targeted training to support consistent application of requirements. •Update policies and procedures to reinforce verification that expenditures are incurred within the approved grant period and are supported by appropriate documentation prior to approval and payment. Anticipated Completion Date: June 30, 2026.
Overpayments to Subrecipients The Division will complete the following corrective actions: •Complete targeted training to support proper implementation of these procedures. •Update procedures to include quality assurance reviews. Anticipated Completion Date: June 30, 2026.
Overpayments to Subrecipients The Division will complete the following corrective actions: •Complete targeted training to support proper implementation of these procedures. •Update procedures to include quality assurance reviews. Anticipated Completion Date: June 30, 2026.
HIV Funds Used for Improper Payment The Department will implement the following corrective actions: •NCDHHS Office of the Controller will update their Standard Operating Procedures (SOP) for Accounts Payable (A/P) Entry when Paying Invoices Having No Reference Identifiers (SOP# AP089) to address the...
HIV Funds Used for Improper Payment The Department will implement the following corrective actions: •NCDHHS Office of the Controller will update their Standard Operating Procedures (SOP) for Accounts Payable (A/P) Entry when Paying Invoices Having No Reference Identifiers (SOP# AP089) to address the case and spacing sensitivity of the North Carolina Financial System (NCFS). •NCDHHS Office of the Controller (OOC) will conduct training to A/P staff on keying payments when an invoice does not have a reference identifier. •NCDHHS, Division of Public Health (DPH) will implement a payment reconciliation procedure within the program area to monitor payments and ensure timely identification and investigation of duplicate payments. •NCDHHS, DPH has requested a repayment from the vendor in the amount of the duplicate payment. Anticipated Completion Date: June 30, 2026.
Deficiencies in Medicaid Provider Payment Process The Department directed the Fiscal Agent to add edit 3406 (History Record Not Found for Adjustment/Void) to the timely filing bypass denial listing, preventing claims denied solely for missing history records from being used to bypass timely filing r...
Deficiencies in Medicaid Provider Payment Process The Department directed the Fiscal Agent to add edit 3406 (History Record Not Found for Adjustment/Void) to the timely filing bypass denial listing, preventing claims denied solely for missing history records from being used to bypass timely filing requirements (FMR 18318). Additionally, the Department directed the Fiscal Agent to research and identify any additional claims paid in error during the audit period because of this system gap (Service ticket 29753). The Department also initiated recoupment of the $170,041.82 overpayment from the provider. Anticipated Completion Date: June 30, 2026.
FFATA Reporting Not Completed See 2025-023 for the Corrective Action Plan.
FFATA Reporting Not Completed See 2025-023 for the Corrective Action Plan.
FFATA Reporting Not Completed The Division of Social Services Budget Office (Division) implemented a corrective action plan focused on staff training, clearer processes, and accountability as noted below. •A training session was conducted for newly hired staff to ensure understanding of the FFATA re...
FFATA Reporting Not Completed The Division of Social Services Budget Office (Division) implemented a corrective action plan focused on staff training, clearer processes, and accountability as noted below. •A training session was conducted for newly hired staff to ensure understanding of the FFATA reporting requirements. •Staff were cross trained to improve the workflow and reduce disruptions during periods of staff shortages or competing priorities. •The Division has updated its FFATA procedures, and a budget analyst has been assigned to each grant to begin the FFATA reporting process. •The Division is completing fiscal year 2026 FFATA reporting to bring all reporting current as part of ongoing operations. •The Division or designee will oversee the reporting process to ensure accuracy and timely reporting. Anticipated Completion Date: June 30, 2026.
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