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Finding 556169 (2024-001)
Significant Deficiency 2024
March 21, 2025 CORRECTIVE ACTION PLAN Pursuant to federal regulations under Uniform Administrative Requirements (2 CFR § 200.511), the following finding was noted in Manistee County’s Single Audit report for the year ended September 30, 2025, along with the corresponding corrective actions to be i...
March 21, 2025 CORRECTIVE ACTION PLAN Pursuant to federal regulations under Uniform Administrative Requirements (2 CFR § 200.511), the following finding was noted in Manistee County’s Single Audit report for the year ended September 30, 2025, along with the corresponding corrective actions to be implemented. Finding: 2024-001 – Child Support Services - Unallowable Costs Auditor Description of Condition and Effect: During the audit of Manistee County’s Child Support Services federal grant expenditures, it was determined that the County lacked effectively operating controls to ensure that salary and wage expenses charged to the Child Support Services program were allowable and properly allocated. As a result, the County received an overpayment of federal funds of $5,528.41 during FY 2024. Auditor Recommendation: It is recommended that the County take actions to strengthen internal controls over payroll expenditures related to federal grants to ensure compliance with federal cost principles and proper expense allocation. Corrective Action: We agree with the finding and will strengthen internal controls over payroll expenditures related to federal grants. We will implement written policies and procedures, provide staff training on federal cost principles, and establish a review process to ensure salary and wage expenses are properly documented and allocated. Additionally, we will work with the grantor agency to resolve the $5,528.41 overpayment. Responsible Person: Susan Zielinski, Finance Director Anticipated Completion Date: September 30, 2025
The Organization has implemented a review and approval of the CEO’s timesheets on a consistent basis.
The Organization has implemented a review and approval of the CEO’s timesheets on a consistent basis.
The purchase of all equipment will follow the pre-approval process stated in the Title 2, Code of Federal Regulations, Part 200, Subpart E, Section 200.439 and implement procedures to address the deficiencies currently identified.
The purchase of all equipment will follow the pre-approval process stated in the Title 2, Code of Federal Regulations, Part 200, Subpart E, Section 200.439 and implement procedures to address the deficiencies currently identified.
View Audit 354835 Questioned Costs: $1
See last page of financial statements
See last page of financial statements
Finding 2024-001—Significant Deficiency in Internal Controls over Compliance: Research and Development Cluster Contact Person: Jennifer Sabbagh Peirce, Senior Director Research Operations, Sponsored Programs Administration and Dr. Andrew Artenstein, Chief Physician Executive and Chief Academic Offic...
Finding 2024-001—Significant Deficiency in Internal Controls over Compliance: Research and Development Cluster Contact Person: Jennifer Sabbagh Peirce, Senior Director Research Operations, Sponsored Programs Administration and Dr. Andrew Artenstein, Chief Physician Executive and Chief Academic Officer, Baystate Health, Inc. Views of Responsible Officials: Management agrees and acknowledges that controls over compliance and documentation of these controls should be assessed and improved. Management highlights that no unallowable charges were incurred and there was no evidence that sponsors were overcharged as a result of the identified deficiencies. Corrective Action Plan and Expected Completion Date: Policies and Procedures – Baystate has already begun a review and revision of policies and procedures that govern sponsored activity in fiscal year 2025. As policies and procedures are revised and finalized, training is provided to the research community, as necessary. This includes effort reporting, subrecipient monitoring and calculations related to salary cap and indirect cost rates. Documentation and Document Maintenance – Baystate is in the process of implementing a pre-award grants system. This electronic system will be the institutional record of all award documentation and award actions. Built into the system are a number of internal controls including workflow approval, tracking and management of award actions and modifications, and management of subrecipient monitoring activities. Salary Cap – Baystate has implemented a number of immediate solutions for salary cap including additional reports to flag salary cap issues. Guidance has been developed and training is underway for individuals that certify effort. In fiscal year 2025, Baystate will consider implementing system delivered functionality in Lawson to manage salary cap calculations. Indirect Rates and Grant Attributes – Implementation of the pre-award grants system will provide an internal control to ensure accurate setup of indirect cost rates and other grant related attributes. These attributes are maintained in the pre-award system based on the sponsor documentation. With each award action and at least annually, Baystate will reconcile attributes between the pre-award system and Lawson to ensure accuracy and completeness. The Corrective Action Plan is expected to be completed by December 2025.
Corrective Action: LSA is committed to strengthening our policies and procedures concerning the management of case files. We will collaborate closely with our Managing Attorneys to ensure that all compliance requirements are met effectively. Regarding the failure to disclose an affirmative filing un...
Corrective Action: LSA is committed to strengthening our policies and procedures concerning the management of case files. We will collaborate closely with our Managing Attorneys to ensure that all compliance requirements are met effectively. Regarding the failure to disclose an affirmative filing under 64 CFR 1644 - LSA does acknowledge that in two cases (from 2022 and 2023), one employee who was new to LSA failed to enter the case information into Legal Server in a timely manner which led to it not being reported in our report. This issue was noted by the individuals Managing Attorney approximately one year ago and measures were put in place at that time to ensure that the information was entered timely. Additionally, the staff person was trained pursuant to the training in our Corrective Action plan last year regarding 1644. These two incidents predate that training. LSA will continue to monitor 1644 information in our system to ensure it is entered timely. Our goal is to ensure full compliance moving forward.
FINDING 2024-002: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement internal controls to ensure timely monthly contributions to the replacement reserve and will address the shortfall by making up the missed deposits in th...
FINDING 2024-002: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement internal controls to ensure timely monthly contributions to the replacement reserve and will address the shortfall by making up the missed deposits in the subsequent period alongside the normal required contributions. Action Taken: The Organization will make the necessary required deposits to bring the balance of the reserve for replacement in alignment with requirements of Section 811 Capital Advance Program Regulatory Agreement.
FINDING 2024-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement a comprehensive internal control system to ensure all tenant files include required documentation, and will conduct a thorough review of all current tena...
FINDING 2024-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement a comprehensive internal control system to ensure all tenant files include required documentation, and will conduct a thorough review of all current tenant files to verify compliance and completeness. Action Taken: Ownership agrees with the auditor’s finding and recommendation and has hired a new management agent to oversee the implementation of a comprehensive internal control system, ensuring all tenant files include required documentation.
FINDING 2024-002: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement a comprehensive internal control system to ensure all tenant files include required documentation, and will conduct a thorough review of all current tena...
FINDING 2024-002: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement a comprehensive internal control system to ensure all tenant files include required documentation, and will conduct a thorough review of all current tenant files to verify compliance and completeness. Action Taken: Ownership agrees with the auditor’s finding and recommendation and Housing Opportunities Corporation will oversee the implementation of a comprehensive internal control system, ensuring all tenant files include all required documentation.
FINDING 2024-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement internal controls to ensure timely monthly contributions to the replacement reserve and will address the shortfall by making up the missed deposits in th...
FINDING 2024-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement internal controls to ensure timely monthly contributions to the replacement reserve and will address the shortfall by making up the missed deposits in the subsequent period alongside the normal required contributions. Action Taken: Management will make the necessary required deposits to bring the balance of the reserve for replacement in alignment with requirements of Section 811 Capital Advance Program Regulatory Agreement.
Residual receipts were not remitted to the residual receipts account in a timely manner. Residual receipts are required to be remitted within 90 days of year-end. In order to avoid this issue in the future, surplus cash will be calculated prior to the audit.
Residual receipts were not remitted to the residual receipts account in a timely manner. Residual receipts are required to be remitted within 90 days of year-end. In order to avoid this issue in the future, surplus cash will be calculated prior to the audit.
Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertificatio...
Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. 3. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 6/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing
Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align reserve balances with...
Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align reserve balances with property needs. Formal Utilization Procedure: A written procedure has been established for requesting and using replacement reserve funds. This includes clear guidelines, approval workflows, and thresholds for reserve levels based on property needs. 3) Monitoring & Reporting: Periodic audits will ensure funds are spent according to HUD guidelines. 4) Staff Training & Oversight: Staff will receive training on proper reserve management, and management will increase oversight to ensure funds are used appropriately. Completion Date: 6/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing
: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will e...
: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 3/28/25 Contact: Jill Lesmerises, CFO
Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training & Oversight: Staff training will be enhanced, and management will increase...
Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training & Oversight: Staff training will be enhanced, and management will increase oversight to ensure compliance. 3) Monitoring and Accountability: Management will regularly review the certification process to ensure all forms are signed by the appropriate certifiers and to verify that all necessary updates are made promptly. Completion Date: 7/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing
Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submit...
Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submitted information (e.g., contacting employers, reviewing documents). 4. Rent Calculation: Rent is recalculated based on updated income and family composition, per HUD guidelines. 5. 50059 Form: Completing the 50059 form accurately is crucial. It documents eligibility, income, and rent calculations. Errors can lead to incorrect rent, delays, or compliance issues. 6. Finalizing Recertification: After verification and accurate completion of the 50059, tenants are informed of any rent changes. 7. Record-Keeping: All recertification documents, including the 50059 form, are filed for compliance and audit purposes. By ensuring that recertifications are done annually, all tenant information is updated, and 50059 forms are accurately completed, doing so maintains program compliance and ensure that tenants are paying the correct rent based on their current financial situation. This is critical not only for HUD compliance but also for ensuring that tenants receive the appropriate level of assistance. Completion Date: 6/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing
We have reviewed the finding regarding the need for a system ensuring that more than one individual holds an EIV (Enterprise Income Verification) license and that the license does not lapse. We understand the importance of maintaining access to the EIV system and ensuring uninterrupted compliance wi...
We have reviewed the finding regarding the need for a system ensuring that more than one individual holds an EIV (Enterprise Income Verification) license and that the license does not lapse. We understand the importance of maintaining access to the EIV system and ensuring uninterrupted compliance with HUD requirements. In response to this finding, we have taken the following corrective actions: 1. Designating Multiple EIV Users: We have implemented a policy that ensures at least two staff members are trained and hold active EIV access. This provides continuity in the event that one staff member is unavailable or the license needs to be renewed. 2. Tracking License Expiration: We have established a system to track EIV license expiration dates and will proactively initiate renewal processes well in advance of any license lapsing. A reminder system has been set up to notify both the employee holding the license and the supervisor, ensuring that renewals are completed on time. 3. Backup Procedures: In addition, we have documented backup procedures to ensure that another individual with the appropriate access is available to perform EIV-related tasks in case of staff turnover or other absences. Anticipated Completion Date: 6/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing
Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertification Process...
Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. 3. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 6/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing
The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensu...
The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 3/28/25 Contact: Jill Lesmerises, CFO
Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training & Oversight: Staff training will be enhanced, and management will in...
Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training & Oversight: Staff training will be enhanced, and management will increase oversight to ensure compliance. 3) Monitoring and Accountability: Management will regularly review the certification process to ensure all forms are signed by the appropriate certifiers and to verify that all necessary updates are made promptly. Completion Date: 7/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing
Plan: We recognize the importance of ensuring timely completion, regardless of turnover at the project level. To address this, we are implementing the following actions: 1. Designated Oversight: The Housing Director, is currently monitoring all major maintenance projects to ensure timely completion...
Plan: We recognize the importance of ensuring timely completion, regardless of turnover at the project level. To address this, we are implementing the following actions: 1. Designated Oversight: The Housing Director, is currently monitoring all major maintenance projects to ensure timely completion and consistency throughout. 2. Clear Reporting: We have established regular progress reports and communication channels to track project timelines and address any potential delays promptly. 3. Accountability Measures: A process has been implemented to ensure that projects are continually monitored and completed as scheduled, even in cases of turnover. Completion Date: 6/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing
Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submit...
Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submitted information (e.g., contacting employers, reviewing documents). 4. Rent Calculation: Rent is recalculated based on updated income and family composition, per HUD guidelines. 5. 50059 Form: Completing the 50059 form accurately is crucial. It documents eligibility, income, and rent calculations. Errors can lead to incorrect rent, delays, or compliance issues. 6. Finalizing Recertification: After verification and accurate completion of the 50059, tenants are informed of any rent changes. 7. Record-Keeping: All recertification documents, including the 50059 form, are filed for compliance and audit purposes. By ensuring that recertifications are done annually, all tenant information is updated, and 50059 forms are accurately completed, doing so maintains program compliance and ensure that tenants are paying the correct rent based on their current financial situation. This is critical not only for HUD compliance but also for ensuring that tenants receive the appropriate level of assistance. Completion Date: 6/30/2025 Contact: Jackie Oliveira-Director of Affordable Housing
We have reviewed the finding regarding the need for a system ensuring that more than one individual holds an EIV (Enterprise Income Verification) license and that the license does not lapse. We understand the importance of maintaining access to the EIV system and ensuring uninterrupted compliance wi...
We have reviewed the finding regarding the need for a system ensuring that more than one individual holds an EIV (Enterprise Income Verification) license and that the license does not lapse. We understand the importance of maintaining access to the EIV system and ensuring uninterrupted compliance with HUD requirements. In response to this finding, we have taken the following corrective actions: 1. Designating Multiple EIV Users: We have implemented a policy that ensures at least two staff members are trained and hold active EIV access. This provides continuity in the event that one staff member is unavailable or the license needs to be renewed. 2. Tracking License Expiration: We have established a system to track EIV license expiration dates and will proactively initiate renewal processes well in advance of any license lapsing. A reminder system has been set up to notify both the employee holding the license and the supervisor, ensuring that renewals are completed on time. 3. Backup Procedures: In addition, we have documented backup procedures to ensure that another individual with the appropriate access is available to perform EIV-related tasks in case of staff turnover or other absences. Anticipated Completion Date: 6/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing
Condition: The Organization did not have documented procurement procedures that were consistent with the standards identified in 2 CFR 200.318(a). Recommendation: Management should draft a formal procurement policy outlining the Organization’s procedures in a manner consistent with the standards id...
Condition: The Organization did not have documented procurement procedures that were consistent with the standards identified in 2 CFR 200.318(a). Recommendation: Management should draft a formal procurement policy outlining the Organization’s procedures in a manner consistent with the standards identified in 2 CFR 200.318(a). Planned Corrective Actions: The Organization agrees with the finding and plans to carry out the recommendation noted above by May 31, 2025.
Finding 556034 (2024-001)
Significant Deficiency 2024
Management agrees with the recommendation and will be transferring all investment balance in obligations of, or fully guaranteed as to principal by, the United States of America in 2025.
Management agrees with the recommendation and will be transferring all investment balance in obligations of, or fully guaranteed as to principal by, the United States of America in 2025.
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