Corrective Action Plans

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The College, upon identification of this issue, recalculated the Pell Grant awards and disbursed the eligible amounts to the 4 students. The College also conducted an internal review of students whose payment period was 3 trimesters based on expected enrollment and identified two additional students...
The College, upon identification of this issue, recalculated the Pell Grant awards and disbursed the eligible amounts to the 4 students. The College also conducted an internal review of students whose payment period was 3 trimesters based on expected enrollment and identified two additional students who only attended the first 2 of the three trimesters; the College recalculated and disbursed the eligible amounts to these two students. Additionally, the College immediately reviewed its procedures and made necessary changes.
Finding 2024‐002: Allowable Costs/Cost Principles (Material Weakness and Noncompliance) Condition: For individuals charged to this program who also have time charged to other programs there were no timesheets or other evidence to support the allocation to the program was based on actual time incurre...
Finding 2024‐002: Allowable Costs/Cost Principles (Material Weakness and Noncompliance) Condition: For individuals charged to this program who also have time charged to other programs there were no timesheets or other evidence to support the allocation to the program was based on actual time incurred to the program but was instead based on the budgeted amounts for those individuals. Corrective Action Planned: -All individuals assigned to multiple contracts will keep time logs of hours workedon each, with a monthly review that the hours align with the budgeted amounts. -In the event hours diverge, workload will be adjusted or a budget adjustment will be requested. Anticipated Completion Date: February 1, 2025 Name of Contact Person Responsible for the Plan: Kimberly Atwood Lepse, Divisional Director of Finance
View Audit 344366 Questioned Costs: $1
February 27, 2025 Finding 2024-001 U.S. Department of Health and Human Services, passed through the Curators of the University of Missouri ALN 93.680 - Medical Student Education PTE Federal Award No: T9952110 Management's Response: Bothwell Regional Health Center will begin performing suspens...
February 27, 2025 Finding 2024-001 U.S. Department of Health and Human Services, passed through the Curators of the University of Missouri ALN 93.680 - Medical Student Education PTE Federal Award No: T9952110 Management's Response: Bothwell Regional Health Center will begin performing suspension and debarment checks on all vendors/contracts funded with grants in 2025. This process will be implemented in 2025 pending policy review processes. Bothwell Regional Health Center will start documenting reviews of suspension and debarment checks of vendors receiving Federal funds while onboarding new vendors and monitoring periodically throughout the year. Views of Responsible Officials and Corrective Action: Management agrees with the finding and management will implement a control process to ensure that suspension and debarment checks are performed on vendors/contracts funded with grants in 2025. Responsible Official: Steven Davis Chief Financial Officer Bothwell Regional Health
Corrective Action Taken: Management notified Eide Bailly of the alleged fraud prior to the start of fieldwork for the October 31, 2024 audit. Management removed all questionable documentation from the tenant files, re-certified any affected tenants and obtained the required documentation for the ten...
Corrective Action Taken: Management notified Eide Bailly of the alleged fraud prior to the start of fieldwork for the October 31, 2024 audit. Management removed all questionable documentation from the tenant files, re-certified any affected tenants and obtained the required documentation for the tenant files prior to the conclusion of the October 31, 2024 audit. Management has also strengthened the controls over the tenant files to ensure that proper documentation is maintained in the tenant files. The Director of Programs is now reviewing the documents in every tenant file at the time of move-in or annual recertification. Name of Contact Person: Julie Sparks, Executive Director, 330-455-9100 Completion Date: February 6, 2024
Corrective Action Taken: Management notified Eide Bailly of the alleged fraud prior to the start of fieldwork for the October 31, 2024 audit. Management removed all questionable documentation from the tenant files, re-certified any affected tenants and obtained the required documentation for the ten...
Corrective Action Taken: Management notified Eide Bailly of the alleged fraud prior to the start of fieldwork for the October 31, 2024 audit. Management removed all questionable documentation from the tenant files, re-certified any affected tenants and obtained the required documentation for the tenant files prior to the conclusion of the October 31, 2024 audit. Management has also strengthened the controls over the tenant files to ensure that proper documentation is maintained in the tenant files. The Director of Programs is now reviewing the documents in every tenant file at the time of move-in or annual recertification. Name of Contact Person: Julie Sparks, Executive Director, 330-455-9100 Completion Date: February 6, 2024
The CIO has already drafted a new suite of 10 IT Policies that address the relevant regulations, including GLBA. Two (2) of the 10 have already been approved by the Senior Leadership Team (SLT) and posted on the College portal, My.Wartburg. The next 4 are currently under review by SLT.
The CIO has already drafted a new suite of 10 IT Policies that address the relevant regulations, including GLBA. Two (2) of the 10 have already been approved by the Senior Leadership Team (SLT) and posted on the College portal, My.Wartburg. The next 4 are currently under review by SLT.
Management has implemented and executed specific corrective actions to address each of HUD’s Findings. The Authority’s Assistant Director, Satyam Polineni has assumed the responsibility of implementing and executing the specific corrective actions and has completed implementation as of February 14,...
Management has implemented and executed specific corrective actions to address each of HUD’s Findings. The Authority’s Assistant Director, Satyam Polineni has assumed the responsibility of implementing and executing the specific corrective actions and has completed implementation as of February 14, 2025.
The County has discussed the finding but must consider the cost of adequate segregation of duties when determining the use of tax money.
The County has discussed the finding but must consider the cost of adequate segregation of duties when determining the use of tax money.
The County has discussed the finding but must consider the cost of professional resources to complete a set of drafted county financial statements.
The County has discussed the finding but must consider the cost of professional resources to complete a set of drafted county financial statements.
Finding 525028 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Condition The change in student status for 12 of the 25 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. However, these students were ultimately reported to the NSLDS. Corr...
Finding 2024-002 Condition The change in student status for 12 of the 25 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. However, these students were ultimately reported to the NSLDS. Corrective Action Plan The Registrar’s Office remains committed to adhering to the College’s established reporting cadence. To ensure compliance with federal requirements, the College submits enrollment data to the National Student Clearinghouse at least every 30 days, maintaining timely and accurate reporting to the National Student Loan Data System. Name(s) of Contact Person(s) Responsible for Corrective Action: Michael Armato, Registrar James Palmer, Director of Institutional Research Anticipated Completion Date: FY2025
The College, upon identification of this issue, immediately reviewed its procedures and made the necessary changes.
The College, upon identification of this issue, immediately reviewed its procedures and made the necessary changes.
Finding 525017 (2024-001)
Significant Deficiency 2024
After the former finance director completed the federal webinars on the guidelines for requesting funds through the Payment Management System and submitting Federal Financial Reports, it was identified and disclosed to the auditors that draw down procedures had not been in compliance. SAMHSA was no...
After the former finance director completed the federal webinars on the guidelines for requesting funds through the Payment Management System and submitting Federal Financial Reports, it was identified and disclosed to the auditors that draw down procedures had not been in compliance. SAMHSA was notified and accounts were reconciled with the return of unspent funds. All drawdowns are currently only occurring when funds are expended. Current finance personnel are trained and have extensive experience in federal reporting guidelines.
Finding: Special Tests and Provisions – Key Personnel Research and Development Cluster, Assistance Listing Number: 84.031S Federal Granting Agency: U.S. Department of Education Program Year 2023–2024 Type of Finding: Other Instance of Noncompliance and Deficiency Corrective Action: The University ha...
Finding: Special Tests and Provisions – Key Personnel Research and Development Cluster, Assistance Listing Number: 84.031S Federal Granting Agency: U.S. Department of Education Program Year 2023–2024 Type of Finding: Other Instance of Noncompliance and Deficiency Corrective Action: The University has a process in place for personnel charged to grants to complete personal activity reports to monitor their level of effort on the grants. We were not requiring key personnel that are providing in-kind services on grants to complete the personal activity reports, although the project directors are monitoring the involvement of all personnel working on grants to ensure we are providing an appropriate level of effort in the grant activities. The individual identified in this finding was providing in-kind services and was not paid from federal funds. The University will update its processes to ensure that that project activity reports are documented and reviewed for all key personnel assigned to grants, including in-kind personnel. Status: In-progress Person Responsible for Implementing: Edith Cogdell, Chief Financial Officer Implementation Date: 05/31/2025
Finding: Special Tests and Provisions – Enrollment Reporting Student Financial Assistance Cluster, Assistance Listing Number 84.268 Federal Direct Student Loans, Assistance Listing Number 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2023–2024 Type of Finding: Other Ins...
Finding: Special Tests and Provisions – Enrollment Reporting Student Financial Assistance Cluster, Assistance Listing Number 84.268 Federal Direct Student Loans, Assistance Listing Number 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2023–2024 Type of Finding: Other Instance of Noncompliance and Deficiency Corrective Action: The failure to report certain enrollment status changes to the NSLDS on a timely basis during the fiscal year ending May 31, 2024, was an isolated instance due to turnover in the Registrar’s Office. The University has updated the process for reporting enrollment status changes to the NSLDS and has ensured there is adequate cross-training in the Registrar’s Office to prevent future instances of non-compliance with reporting deadlines. Status: Completed Person Responsible for Implementing: Melissa Delgado, Registrar Implementation Date: 01/01/2025
Management Response: Holy Family University is dedicated to ensuring the accuracy of our reporting to the NSLDS. The following is how we plan to verify the integrity of our reports. The Registrar's Office will compare the list of students pulled in the monthly NSC process to a report showing all stu...
Management Response: Holy Family University is dedicated to ensuring the accuracy of our reporting to the NSLDS. The following is how we plan to verify the integrity of our reports. The Registrar's Office will compare the list of students pulled in the monthly NSC process to a report showing all students who withdrew that month. This will ensure that we are reporting all withdrawn/graduated students in a timely manner. In addition, the Registrar's Office will verify the potential graduation of students whose grades are changed after the end of the term. If the new grade completes their degree, the student will be reported as "graduated" when we process the next session's graduation applications. This will eliminate the reliance on an external database, as manual updates tend to lack consistency. Lastly, prior to submitting the Graduates Only file to the NSLDS, the Registrar will compare the entire list of graduates to the report showing all students who withdrew throughout the semester. This will be a double check since we will also be checking grade changes, as mentioned above.
Notifications of Disbursements Recommendation: We recommend the College review and strengthen its procedures for notifying students of their Direct Loan disbursements within the required time frame and that documentation of the letters sent is maintained. Explanation of disagreement with audit findi...
Notifications of Disbursements Recommendation: We recommend the College review and strengthen its procedures for notifying students of their Direct Loan disbursements within the required time frame and that documentation of the letters sent is maintained. Explanation of disagreement with audit finding: The Financial Aid Office already has set procedures pertaining to the sending of mass communications to our students whenever Direct Loan disburses. There was an oversight only for the term of Fall 2023 where MCAD failed to launch the communication in a timely manner to disbursement receiving students. Action taken in response to finding: ● The Financial Aid Operations Calendar - will include updated entries concerning the generation of communication for Disbursement Notification. ● Process Update - the sending of the communication will be incorporated into the mass disbursement process at the end of Add/Drop periods during the Fall and Spring terms. Name(s) of the contact person(s) responsible for corrective action: Sherman Lee, Financial Aid Director Planned completion date for corrective action plan: Mar 1, 2025
Awarding of Direct Loans Recommendation: We recommend the College evaluate its procedures and a policy around how level of education is determined and verified when packaging and awarding students. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...
Awarding of Direct Loans Recommendation: We recommend the College evaluate its procedures and a policy around how level of education is determined and verified when packaging and awarding students. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ● Updating the current policy: Financial Aid Office will outline a more thorough policy pertaining to its awarding of additional unsubsidized loan amounts to dependent students. ● Proper documentation concerning the reason for the additional award amount will be required in the specific student’s file in Powerfaids. ● Training sessions will be conducted to assure all members of the Financial Aid Office understands the conditions and expectations from the Department of Education regarding the awarding of additional unsubsidized loans. Name(s) of the contact person(s) responsible for corrective action: Sherman Lee, Financial Aid Director Planned completion date for corrective action plan: May 1, 2025
View Audit 344312 Questioned Costs: $1
Perkins Reconciliation Recommendation: It is recommended that the College review procedures in place to ensure accurate reporting of Perkins loan information to comply with Title IV regulations. Explanation of disagreement with audit finding: MCAD had undergone numerous staff transitions within The...
Perkins Reconciliation Recommendation: It is recommended that the College review procedures in place to ensure accurate reporting of Perkins loan information to comply with Title IV regulations. Explanation of disagreement with audit finding: MCAD had undergone numerous staff transitions within The Business Office. Its previous Perkins Loan Servicer, University Accounting Service (UAS), was derelict in its duty to fulfill the terms of the contract by failing to perform in managing all areas of MCAD’s Perkins Loan portfolio. UAS failed to keep current as well as accurate accounting and funds management records throughout its tenure as the servicer. Action taken in response to finding: ● Changing of Servicer: MCAD has removed UAS and completed the changeover to Heartland Educational Computer Systems Incorporated (ECSI) as its new Perkins servicer. ● Business Office (Student Accounts Manager) will provide close oversight to ensure accountability that ECSI will fulfill its duties and responsibilities as Perkins Loan Servicer ● The Financial Aid Office will partner with the Business Office as another layer of accountability and support to the Business Office as it supervises ECSI. ● Third-Party Assistance: The institution has engaged with CLA to assist with the reconciliation of the Perkins Loan accounts. It is expected that the work CLA has done to assist will come to full fruition and be fully reconciled sometime in 2025. Name(s) of the contact person(s) responsible for corrective action: Mary Alma Noonan, CFO, Brian Braden, Controller and Sherman Lee, Financial Aid Director Planned completion date for corrective action plan: June 30, 2025
Documentation of Review Recommendation: We recommend the College reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Explanation of disagreement with audit finding: MCAD Financial Aid already has sound procedures in place that outlines the process for ou...
Documentation of Review Recommendation: We recommend the College reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Explanation of disagreement with audit finding: MCAD Financial Aid already has sound procedures in place that outlines the process for our internal review and audit processes in all areas (ex. Awarding, Reconciliation, and R2T4). Action taken in response to finding: ● The Director of Financial Aid will ensure regular internal review audits will take place throughout the fiscal year. ● Review results will be documented for recordkeeping and to track whether processes and procedures are followed. ● The Financial Aid Operations Calendar will include dates of when internal reviews will take place over the different areas of the department ● The Business Office will be involved for all reconciliation related internal review processes as a third party reviewer to ensure the disbursed amounts on Powerfaids, COD, and G5 are synchronized. Name(s) of the contact person(s) responsible for corrective action: Sherman Lee, Financial Aid Director Planned completion date for corrective action plan: May 1, 2025
Gramm-Leach Bliley Act (GLBA) Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findi...
Gramm-Leach Bliley Act (GLBA) Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MCAD’s IT department has been working to finalize its WISP protocols to comply with the updated GLBA requirements and ensure the safety and security of data held by MCAD. As we implement the necessary changes required for compliance, our intention is to have these documented and adopted by the end of our fiscal year. Name(s) of the contact person(s) responsible for corrective action: Mary Alma Noonan, CFO and Matthew Hoban, AVP Technology Planned completion date for corrective action plan: May 31, 2025
FINDING 2024-002 – Special Tests and Provisions – Enrollment Reporting: Material Weakness in Internal Control National University acknowledges the findings and the importance of accuracy and timeliness when completing enrollment reporting to NSLDS. The University has made significant efforts to impr...
FINDING 2024-002 – Special Tests and Provisions – Enrollment Reporting: Material Weakness in Internal Control National University acknowledges the findings and the importance of accuracy and timeliness when completing enrollment reporting to NSLDS. The University has made significant efforts to improve all areas of the enrollment reporting process, and the results of this audit do not reflect those efforts and improvements due to the timing of the FY 23 audit completion in February 2024 and CAP completion in June 2024. The institution has identified two items that have resulted in challenges to accurate and timely enrollment reporting during the audit year. Intent to return: The University has identified a need to improve the understanding and implementation of its intent to return (ITR) process. As a result, the University will conduct a holistic review, including assessment and clarification of the current policy, identification and implementation of technological controls, comprehensive training for ITR, and the development and implementation of a monthly ITR review. National Student Clearing House (NSC) reporting: On October 18, 2024, the institution was notified by NSC that its access to process enrollment reporting on behalf of NU was revoked during July 2024, resulting in a reporting gap. The institution is investigating the root cause of this and submitted a ticket to the FPS/SAIG help desk, but no root cause was able to be identified. The issue was immediately resolved upon notification; however, the reporting gap had a significant impact on the FY 24 enrollment reporting sample. In addition to the above, the institution will continue or take the following steps: • Continued monthly testing of enrollment reporting accuracy to NSLDS conducted by the quality assurance team. • Identification and timely delivery of training for areas of opportunity identified in the monthly reviews to the registrar and data operations teams. • Revise the internal documentation process between quality assurance, data operations, and the registrar teams to ensure clarity of policy and regulatory guidance in areas of identified risk/confusion during enrollment reporting processing. Contact Person Responsible for Corrective Action: • Rob Conlon, AVP Financial Aid Compliance • Sarah Massey, AVP of Operations Student Support and Registrar Operations • Gabrielle Witruke, Associate Director Data Analytics • Melissa Diaz, AVP Operations Advising Anticipated Completion Date: March 2025
Management’s Corrective Action Plan National University acknowledges the findings and the recommendations regarding improving procedures. FINDING 2024-001 – Special Tests and Provisions – Return of Title IV: Material Weakness in Internal Control National University acknowledges the finding and impo...
Management’s Corrective Action Plan National University acknowledges the findings and the recommendations regarding improving procedures. FINDING 2024-001 – Special Tests and Provisions – Return of Title IV: Material Weakness in Internal Control National University acknowledges the finding and importance of accurate identification and timely and accurate calculation of R2T4s. The University has made significant efforts to improve all areas of R2T4 processing, and the results of this audit show significant gains over the previous year. Given the timing of the FY 23 audit completion in February 2024 with CAP completion scheduled for June 2024, the benefits of the FY 23 corrective action plan have a limited impact on this audit period. This, coupled with the improved results the institution has seen in timeliness such as the late return error rate having decreased from 31% in FY 23 to 13% in the current audit, suggests that NU is pathing towards compliance with R2T4 requirements. Based on this assessment, NU will continue to take the following actions: • Continual assessment of staffing levels and hiring as needed to ensure timely identification and processing of R2T4s. Staffing ratios were established in FY24 and staffing increases were implemented to ensure accurate processing and timely completion. • Continual identification of risks with weekly testing and readouts from Quality Assurance to the financial aid processing team. • Re-training with the R2T4 processing team on the order of returns. • Identification and timely delivery of training for areas of risk identified in the weekly reviews. • Revise internal processes between the Quality Assurance and financial aid processing to better communicate policy and regulatory guidance in areas of identified risk/confusion during R2T4 processing. Contact Person Responsible for Corrective Action: • Rob Conlon, AVP Financial Aid Compliance • Alan Coddington, AVP Student Financial Services Anticipated Completion Date: January 2025
View Audit 344308 Questioned Costs: $1
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed accurately and on a timely basis. Danita W. Childe...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed accurately and on a timely basis. Danita W. Childers, Executive Director, is responsible for implementing this corrective action by March 31, 2025.
Management has begun staff training, software upgrade for calculating income and qualifying patients within the practice management system, and revising billing team procedures.
Management has begun staff training, software upgrade for calculating income and qualifying patients within the practice management system, and revising billing team procedures.
Finding #2024-00 I - Limited Segregation of Duties (Prior Year Finding #2023-001) Condition: The available office staff precludes a proper segregation of duties in the control ...
Finding #2024-00 I - Limited Segregation of Duties (Prior Year Finding #2023-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Criteria: Internal controls should be in place that provide adequate segregation of duties. Generally, a system of internal control contemplates separation of duties such that no individual has responsibility to execute a transaction, have physical access to the related assets, and have responsibility or authority to record the transaction. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the district's operations. Response: We agree with this finding and continue to work to achieve segregation of duties whenever cost effective. The cash disbursements process includes approval of purchase orders and matching of approved purchase orders with invoices. Review of account coding is performed by the district accounting staff. The payroll disbursement process includes approval of timesheets and review of coding on an ongoing basis. The Board of Education reviews budget to actual information along with disbursement information on a monthly basis. Contact Person: Lisa Wallin-Kapinus Anticipated Completion: Not Applicable
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