Corrective Action Plans

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NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...
NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.
Management will amend each subaward agreement to include all required identifying award information, including the allocation of state and federal funds to the award.
Management will amend each subaward agreement to include all required identifying award information, including the allocation of state and federal funds to the award.
As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are prop...
As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.
NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...
NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
City of Aledo Program Specific Audit Recommendation 2024-001 We recommend that the Organization review the requirements of 2 CFR Section 200.302 to develop allowable cost, activity, and period of performance activities to be followed. Management Response: The organization recognizes the importance o...
City of Aledo Program Specific Audit Recommendation 2024-001 We recommend that the Organization review the requirements of 2 CFR Section 200.302 to develop allowable cost, activity, and period of performance activities to be followed. Management Response: The organization recognizes the importance of having written policies and procedures to ensure cost are allowed and reasonable for the federal program. To address this finding, the agency has implemented the following corrective actions:  Review requirements of 2 CFR Section 200.302 as it relates to internal controls and financial management  Create documented policies and procedures that details how the grantee will review and approve invoices, cost allocation, efforts of personnel, fringe benefits and indirect charges for allowability, adherence to cost principles, accuracy, and completeness  Create documented policies and procedures that details how the grantee will review and approve invoices, cost allocations, efforts of personnel, fringe benefits and indirect charges to ensure they were incurred during the period of performance Responsible Staff: City Official Implementation Date: October 1,2025 90
Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has proper controls in place to document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has proper controls in place to document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will enact a process to ensure all reports are received and approved prior to the reporting deadline. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025
Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: Ther...
Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure casefiles are reviewed consistently and document that review. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025
No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation ...
No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation of approval for all monthly NSLP claims for reimbursement prior to submission. We will establish a formalized procedure to ensure that all monthly claims for reimbursement undergo documented management review and approval before submission. This procedure will clearly define the review process and designate responsible personnel for each step to maintain accountability. All reviewed and approved claims will be accompanied by signed documentation as evidence of compliance. All Food Service personnel involved in the reimbursement submission process will receive training on the new procedure to ensure understanding and adherence to the documentation requirements.
No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage i...
No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage in the accounting system to the approved percentages in the semi-annual time and effort logs to verify accuracy. These improved internal procedures will provide proper compliance over allowable costs. Annual audit of all grant-funded employee positions at the start of each school year, reviewed by grants team, HR, and accounting to verify accuracy of all employee costing allocations to grants.
Finding Reference Number: 2024-001 Management Agent's Certification Description of Finding: The Project is required to obtain a Management Agent's Certification approved by the USDA-RD. The Project did not obtain an approved Management Agent's Certification for the year ended December 31, 2024. Stat...
Finding Reference Number: 2024-001 Management Agent's Certification Description of Finding: The Project is required to obtain a Management Agent's Certification approved by the USDA-RD. The Project did not obtain an approved Management Agent's Certification for the year ended December 31, 2024. Statement of Concurrence or Nonconcurrence: The Project agrees with the audit finding. Corrective Action: The management certification from 3560-13 has been sent to the board president for signature on September 24, 2025, and will be submitted to USDA once received back. Name of Contact Person: Paula Tracy, President, 860-398-5425 ext. 511# paulat@wildwoodmgt.com Projected Completion Date: Management certifications have been e-mailed to the board president on September 24, 2025 and once received back will forward to USDA for final signature.
2024 -002 Documentation of Procurement History Corrective Action Plan: The Standard Operating Procedures currently outlines procurement based on Uniform Guidance. Additional procedures will be implemented to ensure compliance with the policy. An internal Procurement Checklist and Pre-Award Review Fo...
2024 -002 Documentation of Procurement History Corrective Action Plan: The Standard Operating Procedures currently outlines procurement based on Uniform Guidance. Additional procedures will be implemented to ensure compliance with the policy. An internal Procurement Checklist and Pre-Award Review Form prepared by the Chief Operating Officer will be implemented to ensure compliance is documented before federal funds are expended. That document will be reviewed and approved by the President / CEO. All procurements over the simplified acquisition threshold will be reviewed by the Chief Operating Officer for compliance before a purchase order is issued or a quote is approved. All vendors solicited for proposal on procurements over the simplified acquisition threshold will be discussed during board meetings and documented in board meeting minutes. Personnel Responsible for Corrective Action: Alison Elder, CFO Anticipated Completion Date: May 2025
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.
PHA Response and Action Plan- Management continues to resolve old tenant filed deficiencies lacking required documentation. While 55% failure rate is unacceptable, please note the 2023 audit file review was a 100% failure rate for this component. Management will resolve deficiency before end of the ...
PHA Response and Action Plan- Management continues to resolve old tenant filed deficiencies lacking required documentation. While 55% failure rate is unacceptable, please note the 2023 audit file review was a 100% failure rate for this component. Management will resolve deficiency before end of the 2025 FYE.
PHA Response and Action Plan- Financial department management has been in contact with the Internal Revenue Service for the transfer of credentials from the previous management agent to Mission HA. This process has been tedious and at times unresponsive. We are currently working with the IRS for cha...
PHA Response and Action Plan- Financial department management has been in contact with the Internal Revenue Service for the transfer of credentials from the previous management agent to Mission HA. This process has been tedious and at times unresponsive. We are currently working with the IRS for change of credentials and submission of all pending 941 payments. Deficiency will be resolved before close of 2025 FYE
Finding 1159428 (2024-002)
Material Weakness 2024
Mhub
IL
Condition: The Organization did not have controls to retain documentation that the procurement process was followed to ensure more than one vendor was reviewed for pricing before selecting the vendor chosen (as required under 2 CFR 320(a)(2)(i)). Planned Corrective Action: Management will implement ...
Condition: The Organization did not have controls to retain documentation that the procurement process was followed to ensure more than one vendor was reviewed for pricing before selecting the vendor chosen (as required under 2 CFR 320(a)(2)(i)). Planned Corrective Action: Management will implement controls to ensure proper support of the procurement process is retained. Contact person responsible for corrective action: Manas Mehandru, COO Anticipated Completion Date: December 31, 2025
View Audit 370163 Questioned Costs: $1
September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an...
September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an unusual reallocation of funding by the Washington State Department of Commerce. The award was originally awarded and recorded as state funds. In September 2024, the Washington State Department of Commerce reallocated a portion of its funding and amended the grant terms to designate the award as being funded under the Coronavirus State and Local Fiscal Recovery Funds (21.027). Because the reallocation and revised terms were communicated late in the fiscal year, management did not identify the change in time to ensure that the award was correctly reported as federal on the SEFA. The adjustment was therefore an oversight and not an intentional misclassification. 2024-001 Preparation of the Schedule of Expenditures of Federal Awards CCAP Executive Leadership understands the function and necessity of preparing a complete and accurate SEFA. 1. Policy and Procedures Development: By November 15, 2025, management will develop and adopt written policies and procedures requiring formal review of all grant amendments, reallocations, and correspondence from pass-through entities to determine whether funding sources have changed and whether SEFA reporting is affected. 2. Internal Control Implementation: Management will implement a dual-review process in which both the Finance Director and Grants Manager verify the funding source and assistance listing number for all awards and amendments before SEFA preparation. 3. Training: Staff responsible for grants management and financial reporting will complete training on Uniform Guidance financial management and SEFA preparation requirements by November 15, 2025, with refresher training annually thereafter. 4. Ongoing Monitoring: Management will conduct a pre-audit SEFA review each year, reconciling all awards and amendments to source documentation, including grant agreements, amendments, and communications from pass-through entities. Responsible Party: Lucy Machowek, CFO Planned Completion Date: November 15, 2025
Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the ...
Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the support and documentation we provided we captured $191,000 (25% non-federal match) of in-kind to meet our obligation of $189,250 for grant award Year 1, 2023. And although we met our in-kind obligation, we experienced several delays which were recognized by our grantee, MBDA. The delay in funding the grant award took place from July 2023 to September 2023 and subsequently after funding was released an additional black-out period from September 2023 to October 2023 was experienced due to a system transition from BAS to GEMS/era Commons. Acknowledgement of these delays was addressed by an official during an MBDA All Equities call on October 18, 2023. During that call awardees were advised to continue focusing on our program activities and clients as the situation was being addressed. To account for the delays, we later submitted a budget revision request through the new system, eRA Commons on 12.09.2024 asking for a budget carryover of $337,825.00 which also outlines how the funds will be expended. Additionally, it is noted in your finding that the allowable in-kind contribution is being reduced given that budget categories were not met by line item. However, our interpretation of MBDA Capital Readiness NOFO (pg.14), we are directed to Section CFR200.306 [https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-D/section-200.306] which does not cap in-kind by line-item. Lastly, the MBDA organization has changed dramatically since the inception of the Capital Readiness grant in 2023, yet we have been in communication with an MBDA government official who acknowledges the delays during the time outlined above and ask that flexibility for this non-federal share requirement be re-considered. Supporting documentation has been sent to support the statements. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: We plan to continue to seek validation of our position from our grantor and grant management entity – 4th Quarter 2025.
View Audit 370152 Questioned Costs: $1
Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving lim...
Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving limited time for an adequate transfer of knowledge and responsibilities. To preserve continuity in financial operations, CRMSDC immediately engaged outsourced accounting support. Looking ahead, CRMSDC will undertake a full review of its financial management structure and secure a highly qualified accountant or financial professional with specialized expertise in nonprofit accounting and federal grant compliance. Combined with strengthened procedures and enhanced supervisory oversight, these actions will build organizational capacity, reinforce internal controls, and ensure accurate and timely financial reporting. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: Assessment and Correction – 4th Quarter 2025
Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to g...
Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to grants. Additionally, in the transactions tested for ALN 66.615, there was no sufficient documentation to support the total fringe benefit amounts charged to the grants. Repeat Finding: Yes, similar deficiencies noted in 2023‐003. Views of Responsible Officials: There was a finding that was noted related to the tracking of personnel costs to the federally funded contract. SEE Accounting and Administration, which includes HR, has established and implemented uniform timekeeping procedures requiring all employees, both exempt and non-exempt, whose salaries are charged to federal contracts to submit accurate and complete timecards that reflect the actual hours worked. These formal procedures are monitored, reviewed, and reconciled on a monthly basis. Official Responsible for Ensuring CAP: Jennifer Hoffman, CEO; Anna Zaricki, CFO; Trevis Bird, COO; Monique Gutierrez, Sr-HRD; Arthur Doi, Controller; and Justin Yamashiro, Audit Manager are responsible for ensuring corrective action is implemented. Planned Completion Date for CAP: December 31, 2026
View Audit 370147 Questioned Costs: $1
Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the Decemb...
Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO
Views of Responsible Officials and Planned Corrective Action: The Authority contracted with an Agency which performed all rent reasonableness calculations, however, a copy of the calculations could not be located at the time of audit. The Authority has implemented a process whereby all completed ren...
Views of Responsible Officials and Planned Corrective Action: The Authority contracted with an Agency which performed all rent reasonableness calculations, however, a copy of the calculations could not be located at the time of audit. The Authority has implemented a process whereby all completed rent reasonableness calculations will be stored in the related tenant file. Terrence Corriston, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...
In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
View Audit 370140 Questioned Costs: $1
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