Corrective Action Plans

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Corrective Action: The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Ro...
Corrective Action: The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Roman, Finance Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will integrate suspension and debarment verification into purchasing workflow; require verification prior to purchase order approval; and update procurement policy to clearly define compliance requirements and documentation standards. Responsible Individual(s): Michael El...
Corrective Action: The City will integrate suspension and debarment verification into purchasing workflow; require verification prior to purchase order approval; and update procurement policy to clearly define compliance requirements and documentation standards. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Crissy Cantu, Purchasing Manager. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will implement standardized inventory management procedures for federally funded assets; maintain detailed item-by-item inventory records; conduct periodic management reviews of inventory listings; and ensure all required equipment is properly tracked and reported. Respon...
Corrective Action: The City will implement standardized inventory management procedures for federally funded assets; maintain detailed item-by-item inventory records; conduct periodic management reviews of inventory listings; and ensure all required equipment is properly tracked and reported. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Roman, Finance Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into departmental procedures. Responsible Individual(s): Michael El...
Corrective Action: The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into departmental procedures. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will implement and enforce procedures requiring purchase orders or equivalent authorization documentation to be prepared, approved, and retained prior to incurring federally funded expenditures. The City will also implement review procedures to ensure supporting documenta...
Corrective Action: The City will implement and enforce procedures requiring purchase orders or equivalent authorization documentation to be prepared, approved, and retained prior to incurring federally funded expenditures. The City will also implement review procedures to ensure supporting documentation is complete and maintained in grant expenditure files. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Crissy Cantu, Purchasing Manager. Timeline: In Progress. Estimated October 2026.
Corrective Action: The City will implement formal Section 3 policies and procedures for applicable CDBG projects. The policies will identify applicable projects, assign responsibility for compliance monitoring, establish worker certification and documentation requirements, and provide for documentat...
Corrective Action: The City will implement formal Section 3 policies and procedures for applicable CDBG projects. The policies will identify applicable projects, assign responsibility for compliance monitoring, establish worker certification and documentation requirements, and provide for documentation retention and periodic review procedures. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated October 2026.
Corrective Action: The City will implement formal procedures to ensure pre-rehabilitation inspection documentation is reviewed and approved by the designated approving authority. Procedures will clearly assign preparer and reviewer responsibilities, maintain appropriate segregation of duties, and re...
Corrective Action: The City will implement formal procedures to ensure pre-rehabilitation inspection documentation is reviewed and approved by the designated approving authority. Procedures will clearly assign preparer and reviewer responsibilities, maintain appropriate segregation of duties, and require supporting documentation to be retained in project files. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated October 2026.
Corrective Action: The City will establish a centralized grant reporting calendar to monitor federal reporting deadlines; assign responsibility for the timely preparation and submission of required reports; and implement review procedures to ensure compliance with federal reporting requirements. Res...
Corrective Action: The City will establish a centralized grant reporting calendar to monitor federal reporting deadlines; assign responsibility for the timely preparation and submission of required reports; and implement review procedures to ensure compliance with federal reporting requirements. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City has begun implementing formal equipment management procedures for federally funded assets, including the green tagging of grant-funded assets utilizing the RCI asset management system. The City will conduct and document a physical inventory of federally funded equipment a...
Corrective Action: The City has begun implementing formal equipment management procedures for federally funded assets, including the green tagging of grant-funded assets utilizing the RCI asset management system. The City will conduct and document a physical inventory of federally funded equipment at least once every two years; reconcile inventory results to property records; investigate discrepancies timely; and retain supporting documentation to demonstrate compliance with federal equipment management requirements. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Roman, Finance Director. Timeline: In Progress. Estimated September 2026.
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Management’s response/corrective action plan: The School Business Manager and the Assistant Superintendent/Special Education Director will ensure all contracts going forward will have the contract language necessary to prevent using any parties who have been suspended or debarred.
Management’s response/corrective action plan: The School Business Manager and the Assistant Superintendent/Special Education Director will ensure all contracts going forward will have the contract language necessary to prevent using any parties who have been suspended or debarred.
2025-001 Internal Controls over Allowable Cost – Disaster Assistance Grants Point of Contact: Rachael Wilkinson, Director, APOHSEP Management’s response and corrective action plans are as follows: 1. Management acknowledges the recommendation and has taken steps to enhance oversight of the Federal E...
2025-001 Internal Controls over Allowable Cost – Disaster Assistance Grants Point of Contact: Rachael Wilkinson, Director, APOHSEP Management’s response and corrective action plans are as follows: 1. Management acknowledges the recommendation and has taken steps to enhance oversight of the Federal Emergency Management Agency (FEMA) reimbursement requests, including those prepared by third-party consultants. Ascension Parish Government is implementing a formalized review process by the Ascension Parish Office of Homeland Security and Emergency Preparedness (APOHSEP) prior to submission to ensure that all expenditures are accurate, properly supported, and classified in accordance with FEMA requirements. 2. This process will include reconciling reimbursement requests with underlying payroll records, equipment logs, and other supporting documentation, as applicable. Management will continue to monitor FEMA submissions to ensure compliance with applicable federal guidelines and strengthen documentation of review procedures. 3. Additionally, Ascension Parish Government will amend the project worksheet to address the identified errors
Finding 2025-002: Community Development Block/Grants/ State's Program and Non-Entitlement Grants in Hawaii Assistance Listing No. 14.228 Compliance Requirement: Special Tests and Provisions Grant No.: Not applicable Type of finding: Internal Control (material weakness) and Compliance (material nonco...
Finding 2025-002: Community Development Block/Grants/ State's Program and Non-Entitlement Grants in Hawaii Assistance Listing No. 14.228 Compliance Requirement: Special Tests and Provisions Grant No.: Not applicable Type of finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The City should establish and implement formal policies and procedures requiring weekly certified payrolls be obtained and reviewed against the applicable Davis-Bacon wage requirment before contractor payment. The review should be documented and include evidence of comparison of labor classifications, wage rates, fringe benefits, and reviewer approval. Action Taken: Management will establish comprehensive, formal policies and procedures to ensure strict compliance with Davis-Bacon regulations alongside all applicable federal and state grant requirments. If there are questions regarding this plan, pleasecall the responsible parties listed below. Sincerely yours, Heather Sanchez City Manager City of Alamosa, Colorado Emily Martinez Finance Director City of Alamosa, Colorado
The City will establish and document formal subrecipient-monitoring procedures consistent with 2 CFR §200.332. The audit found that the City did not document its review of the subrecipient's Single Audit report, evaluate whether the subrecipient's audit finding related to City-provided funds, or fol...
The City will establish and document formal subrecipient-monitoring procedures consistent with 2 CFR §200.332. The audit found that the City did not document its review of the subrecipient's Single Audit report, evaluate whether the subrecipient's audit finding related to City-provided funds, or follow up on discrepancies in the subrecipient's Schedule of Expenditures of Federal Awards. 1. Maintain a complete inventory of all federal subawards, including the subrecipient, federal program, Assistance Listing Number, award amount, period of performance, and applicable compliance requirements. 2. Require each subrecipient to submit its annual Single Audit report or written confirmation that it was not subject to the Single Audit requirement. 3. Review each applicable Single Audit report and the Federal Audit Clearinghouse for findings that could relate to City-funded subawards. 4. Compare subaward information reported by the subrecipient on its Schedule of Expenditures of Federal Awards to the City's accounting and grant records. 5. Investigate and resolve any reporting discrepancies, including missing pass-through entity information, incorrect Assistance Listing Numbers, or omitted federal expenditures. 6.. Use a standardized monitoring checklist and retain all supporting documentation in the applicable grant file. Responsible Officials Anticipated Completion Date The revised monitoring checklist will be completed by September 30, 2026. Review and follow-up concerning the identified subrecipient will be completed by December 31 , 2026. Monitoring will continue throughout the duration of each subaward. Contact Person Responsible for the Corrective Action Plan Cynthia Smith, Finance Director City of Chicago Heights 1601 Chicago Road Chicago Heights, Illinois 60411
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient ...
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient to support compensation costs charged to the Community Development Financial Institutions Program in accordance with 2 CFR § 200.430. The Organization's methodology relied on management-established allocation percentages based on employee responsibilities and anticipated level of effort supporting CDFI Fund activities. While management believes the costs charged to the award were incurred in support of eligible program activities, the Organization recognizes that documentation supporting the allocation methodology did not meet the standards required under Uniform Guidance. Planned Corrective Action: Beginning July 1, 2026, the Organization will implement formal time and effort reporting procedures for all personnel whose compensation is charged, in whole or in part, to federal awards. Specifically, the Organization will: 1.The CFO will establish a cost allocation plan which includes a methodology to support salary, wage, and fringe benefit charges, and other applicable costs, to the federal award and to support allocation among cost objectives. 2. The CFO will implement a documented process for personnel activity reporting and/or periodic certifications (or other equivalent documentation) that reasonably reflects actual work performed and supports the allocation of compensation costs to eligible activities. 3. CFO will reconfigure the current workforce management system to ensure projects, departments, and contextual details are logged at the source. 4. The COO will review existing timesheet submission and review policy to ensure compliance with federal requirements. The policy will require supervisory review and approval of personnel activity documentation/ certifications consistent with the payroll cadence and retain documentation in the grant file and/or payroll file. The CFO will review and enforce compliance with timesheet submission requirements. 5. The CFO will implement a dynamic allocations module within Sage Intacct to facilitate automated allocation of time and fringe benefits to federal and other programs. 6. The CFO will ensure that the systems established perform periodic reconciliation and after-thefact review of payroll and fringe benefit allocations. The CFO will make timely adjustments when actual activity differs from budget estimates or planned allocations. 7. The CFO, COO, and other personnel working on federal programs will receive training on the documentation standards in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 8. The CFO and COO will provide training to program and finance personnel on the documentation standards. in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 9. The CFO will, as part of the monthly close process, review compensation charged to federal awards to ensure all costs are appropriate and supported prior to requesting reimbursement. Management believes these actions will strengthen internal controls over compensation costs charged to federal awards and ensure compliance with Uniform Guidance requirements going forward. Responsible Official: Julia Gazizova, Chief Financial Officer Anticipated Completion Date: September 30, 2026.
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Finding #2025-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: Management of the System has reviewed the financial statements and schedule of expenditures of federal awards (SEFA) ...
Finding #2025-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: Management of the System has reviewed the financial statements and schedule of expenditures of federal awards (SEFA) prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the System. Management and the Board of Directors has been given adequate opportunity to ask questions regarding the financials statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Anticipated Completion Date: Ongoing
Finding 1224786 (2025-002)
Material Weakness 2025
Ecotrust is implementing a formal, documented, risk based approach to subrecipient monitoring consistent with 2 CFR 200.332. Approximately three years ago, following turnover, Ecotrust shifted grantee and sub grantee management from a centralized model to a distributed model in which program manager...
Ecotrust is implementing a formal, documented, risk based approach to subrecipient monitoring consistent with 2 CFR 200.332. Approximately three years ago, following turnover, Ecotrust shifted grantee and sub grantee management from a centralized model to a distributed model in which program managers assumed responsibilities for which tools and training were insufficient. To correct the underlying deficiency, Ecotrust is taking the following specific actions: • Adopting formal, written policies and procedures that require a documented risk assessment for each subrecipient and require that assessed risk drive the level of monitoring. • Performing and documenting a risk assessment for every subrecipient, including documented consideration of each subrecipient’s audit results and prior year findings. • Using the assessed risk to determine and document the nature, timing, and extent of monitoring, applying enhanced monitoring procedures to higher risk subrecipients and retaining documentation supporting the performance and results of those procedures. • Engaging an outside consultant, Jennifer Hutton, who has grantee management experience gained at Mercy Corps and other non profits, to work with the finance team and program managers to develop the supporting processes, tools, and accountability measures, supported by training for all participants.
Finding 1224785 (2025-001)
Material Weakness 2025
Ecotrust is strengthening its controls over federal financial reporting to ensure required SF‑425 Federal Financial Reports are submitted (in a timely manner) in accordance with 2 CFR 200.328 and applicable award terms. Approximately three years ago, following turnover, Ecotrust shifted grantee and ...
Ecotrust is strengthening its controls over federal financial reporting to ensure required SF‑425 Federal Financial Reports are submitted (in a timely manner) in accordance with 2 CFR 200.328 and applicable award terms. Approximately three years ago, following turnover, Ecotrust shifted grantee and sub‑grantee management from a centralized model to a distributed model in which program managers assumed responsibilities for which tools and training were insufficient. To correct the underlying deficiency, Ecotrust is taking the following specific actions: • Assigning clear, documented responsibility for the preparation and timely submission of all federal financial reports (including the SF‑425), with a designated primary preparer and a backup to ensure continuity of reporting during staff absences or turnover. • Establishing a federal reporting calendar that tracks all federal financial report due dates, with proactive advance reminders shared across the finance and program teams. • Providing periodic training to finance and program staff to reinforce awareness of federal financial reporting requirements and deadlines. • Engaging an outside consultant, Jennifer Hutton, who has grantee‑management experience gained at Mercy Corps and other non‑profits, to work with the finance team and program managers to develop the supporting processes, tools, and accountability measures.
Finding #2025-002 – Material Weakness and Material Noncompliance. U. S. Department of Housing and Urban Development, Community Development Block Grants/Entitlement Grants, Assistance Listing #14.218, Passed through the City of Houston, Contract year: 11/07/23 – 10/31/26. Condition and context: Manag...
Finding #2025-002 – Material Weakness and Material Noncompliance. U. S. Department of Housing and Urban Development, Community Development Block Grants/Entitlement Grants, Assistance Listing #14.218, Passed through the City of Houston, Contract year: 11/07/23 – 10/31/26. Condition and context: Management failed to include a federally funded contract on the SEFA for the last two years totaling $522,014. Omitting these expenditures from the SEFA resulted in incorrectly reported federal expenditures. Recommendation: Develop policies and procedures to identify and reflect all federal programs on the SEFA and reconcile the federal expenditures to the federal program revenue on a routine basis. Planned corrective action: The Vice President of Finance and Administration will be provided with all funding agreements to identify any new federal grants. Additionally, the project management team and the Vice President of Finance and Administration will now meet bi-weekly to discuss new funding agreements in order to identify any new funding that is federally sourced and would require inclusion on the SEFA. Responsible officer: Michele Nezi Marvin, Vice President of Finance and Administration. Estimated completion date: July 1, 2026.
Managements Corrective Action Plan Year Ending – December 31, 2025 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2025. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2025-001 – Allowable Cost Principles – Payro...
Managements Corrective Action Plan Year Ending – December 31, 2025 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2025. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2025-001 – Allowable Cost Principles – Payroll Evidence of Review Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2026 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky will implement a process improvement plan in 2026 that addresses the finding: • For our 2025 Single Audit, we discovered a system limitation in Dayforce preventing approval of timecards beyond the automatic cut-off time. • In partnership with the Human Resources department, staff will establish an “after the fact” approval process to ensure that all timecards are reviewed and approved by management. o The current system will continue to push through timecards to make the defined payroll cut-off time. o A manual process will be established to review and approve missed timecards after payroll is processed. ▪ Managers are to review and approve timecards, even though the timecards have been processed. ▪ A log will be maintained acknowledging missed approvals, logging hours, areas of work, and manager approval o If any errors or changes need to be made, those will be reflected within the next payroll cycle.
The Shaquille O'Neal Foundation acknowledges the observation regarding the documentation requirements under 2 CFR §200.318(a). While the Foundation did not have a formal written procurement policy in place during the audit period, it did implement procurement practices designed to comply with the Un...
The Shaquille O'Neal Foundation acknowledges the observation regarding the documentation requirements under 2 CFR §200.318(a). While the Foundation did not have a formal written procurement policy in place during the audit period, it did implement procurement practices designed to comply with the Uniform Guidance requirements. Specifically, the Foundation maintained oversight of contractor performance in accordance with 2 CFR §200.318(b) by ensuring that all contractor agreements and applicable purchase orders incorporated the required federal contract provisions and procurement language. The Foundation monitored contractor performance to verify that work was completed in accordance with the terms, conditions, and specifications of each agreement. The Foundation recognizes that documenting these procurement procedures in a formal written policy is a separate requirement under 2 CFR §200.318(a). To address this deficiency, management has developed and adopted a written Procurement Policy that aligns with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 CFR Part 200). The policy formalizes the Foundation's procurement procedures, internal controls, competition requirements, contract oversight responsibilities, and documentation standards to ensure ongoing compliance with federal regulations. Management believes this corrective action fully addresses the audit finding and strengthens the Foundation's procurement governance for future federal awards.
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environm...
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environment. The Foundation maintains controls designed to ensure that expenditures charged to federal awards are reviewed for allowability, properly supported, and approved before submission for reimbursement. In this instance, a subsequent reimbursement from the lender was not identified through the Foundation's normal monitoring process. Management contacted the grantor and resolved the matter by applying other allowable expenditures to the federal award, thereby eliminating any duplicate recovery of federal funds. To further strengthen existing controls, the Foundation has enhanced its procedures to specifically track expenditures submitted for reimbursement under federal programs and monitor any subsequent refunds, credits, rebates, or reimbursements received from vendors or other third parties related to those expenditures. In addition, management will document a post-submission review process to identify vendor credits or recoveries received after reimbursement requests have been submitted and determine whether any adjustment to future reimbursement requests or repayment to the granting agency is required.
Contact Person Mark Kinzler, General Manager Corrective Action Plan All mileage charged to federal awards will be capped at the allowable federal rate to ensure any internal mileage rates exceeding this cap will be covered by non-federal or unrestricted funds. Completion Date Immediate
Contact Person Mark Kinzler, General Manager Corrective Action Plan All mileage charged to federal awards will be capped at the allowable federal rate to ensure any internal mileage rates exceeding this cap will be covered by non-federal or unrestricted funds. Completion Date Immediate
The Airport has incorporated the addition of electronic approvals for Airport Improvement Plan invoices within its existing procurement policy.
The Airport has incorporated the addition of electronic approvals for Airport Improvement Plan invoices within its existing procurement policy.
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