Corrective Action Plans

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Head Start of Lane County has created a paln with assitance of Wipfli to complete outstanding audits. See corrective action item 2022-004 for more details. The agency has implemented a yearly closeout starting in the year 2024-2025 going forward. This will allow for timely audit preparation, reconci...
Head Start of Lane County has created a paln with assitance of Wipfli to complete outstanding audits. See corrective action item 2022-004 for more details. The agency has implemented a yearly closeout starting in the year 2024-2025 going forward. This will allow for timely audit preparation, reconciliations and adjustments to occur
BRISTOW HOUSING AUTHORITY 1110 S. Chestnut Bristow, OK 74010 Phone No. (918) 367-5558 Fax No. (918) 367-2341 HOUSING AUTHORITY OF BRISTOW, OKLAHOMA CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 Corrective Action Plan Finding: 2022-001-Inadequate Internal Controls Over Disbursements and Payables-Al...
BRISTOW HOUSING AUTHORITY 1110 S. Chestnut Bristow, OK 74010 Phone No. (918) 367-5558 Fax No. (918) 367-2341 HOUSING AUTHORITY OF BRISTOW, OKLAHOMA CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 Corrective Action Plan Finding: 2022-001-Inadequate Internal Controls Over Disbursements and Payables-Allowable Costs Condition: (a)-We reviewed an initial sample of 60 disbursements for the General Fund that covers the Low Rent program. 24 disbursements that totaled $27,455 either had no documentation or inadequate documentation. All of the payees appeared to be normal vendors used in the Authority’s regular business dealings. (b)-We reviewed 36 Section 8 disbursements. We noted no exceptions in our review of supporting information or cancelled checks for these disbursements. (c)-In our substantive other tests, we reviewed 13 other disbursements which totaled $19,790 which were not supported by invoices. All of the payees appeared to be normal vendors used in the Authority’s regular business dealings. (d)-Payroll taxes, payments to the IRA Simple Plan, and payments to various vendors were not timely paid, and significant amounts were owed at year-end. Corrective Action Planned I am Charles Unsell, Executive Director of the Housing Authority of the City of Shawnee, Oklahoma and Designated Person to answer these findings. The Shawnee PHA executed a Cooperative Agreement with the Bristow Housing Authority, effective December 1, 2023. The Agreement was subsequently extended through November 30, 2025. We have worked diligently to address and correct the deficiencies that we have encountered. Person responsible for corrective action: Charles Unsell, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026
Finding 1175571 (2022-009)
Material Weakness 2022
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
Finding 1175570 (2022-008)
Material Weakness 2022
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
Finding 1175569 (2022-007)
Material Weakness 2022
The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.
The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.
Finding 2022-015 Allowable Costs and Activities Individual(s) Responsible: Tribal Council; Michelle Thomas, Acting Executive Director; Tyce Martin, HR Generalist; Program Directors; and Enterprise Managers. Action: The current Tribal Council will ensure that all required documentation is maintained ...
Finding 2022-015 Allowable Costs and Activities Individual(s) Responsible: Tribal Council; Michelle Thomas, Acting Executive Director; Tyce Martin, HR Generalist; Program Directors; and Enterprise Managers. Action: The current Tribal Council will ensure that all required documentation is maintained as supporting backup for all purchase requisitions, including proper signatures, prior authorization, and related approvals. In addition, all employees will have appropriate Personnel Action Notices (PANs) on file, and all timesheets will be properly completed and signed by both the employee and their supervisor. Anticipated Completion Date: March 2026.
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to documen...
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to document that it had been approved by management to pay. During this period of 2022 we were on a manual accounts payable system. Invoices were approved before payment was made by email and the email was to be printed and attached. In September of 2022 we implemented a new ERP system. This system requires electronic approval by management for the invoice to be paid. Ferrick Jones, Controller, is responsible for ensuring this is remediated.
Management's response: When the federal grant award came out at the end of December 2021 , we did not get an approved budget and signed contract for work with the State until the beginning of July 2022 for work that dated back to October 1, 2021 . Because we did not have a signed contract until so l...
Management's response: When the federal grant award came out at the end of December 2021 , we did not get an approved budget and signed contract for work with the State until the beginning of July 2022 for work that dated back to October 1, 2021 . Because we did not have a signed contract until so late into the grant {even though we knew the grant was coming and had already started the work to support Afghans as they arrived in Tulsa). we did not have full guidance or understanding as to how the funds had to be invoiced/spent. In March, we purchased gift cards for clients for immediate needs, and while we had sufficient documentation about the purchase of the gift cards, we did not have the back-up documentation that showed their distribution to clients. We also were not aware that the late fees could not be charged as they were incurred.Finally, as the work started, we knew that our overall indirect costs were greater than what was budgeted .Because we knew our costs were greater than the 10% budgeted, we simply billed the full amount budgeted towards indirect costs during each month, and failed to adjust based on actual direct costs invoiced to the grant. This was a misunderstanding on our part of how that budgeted item needed to be invoiced, and we have since corrected this. Views of Responsible Officials and Corrective Action : Immediately after receiving feedback from ouraudits about gift cards, we created an additional process where if we purchase or receive gift cards, we have team members check out those gift cards and include which clients the gift cards are going to so we can track those. Overall, we try not to utilize gift cards when possible, and have removed those purchases on federa l grants. We have also made sure to no longer include any late fees on grants moving forward, and have internal reviews from our Grants Accountant and Senior Director of Finance to help track for that. budgeted line item.Finally, in 2023, we fi xed our indirect cost billing to make sure that it matched our direct costs and not the budgeted line item. Name of Contact Person: Name:Julie Davis Title Chief Executive Officer Email: juliedavis@ywcatulsa.org Phone: 918-828-2346 Projected Implementation: The implementation is complete.
Management's response: When the federal grant award came out at the end of December 2021, we did not get an approved budget and signed contract for work with the State until the beginning of July 2022 for work that dated back to October 1, 2021. Because of this, once we were able to begin invoicing,...
Management's response: When the federal grant award came out at the end of December 2021, we did not get an approved budget and signed contract for work with the State until the beginning of July 2022 for work that dated back to October 1, 2021. Because of this, once we were able to begin invoicing, we utilized percentage allocations for employee's t ime, knowing that the majority of the employees had been doing work tied to the grant were allocated 100% to the grant and that significant time had been going to building up for the grant. However, it was not possible to go back and get time sheets that were tied to the grant for the majority of 2022 because we simply didn't have a contract in place yet. At the end of 2022, we began to utilize a more structured process for tracking allocations, requiring leadership to review their team member's allocations to grants on a quarterly basis and submit those to our Finance, HR, and Grants Compliance team to review. Because this didn't happen early enough in 2022, we did not have enough backup documentation to support the allocations based on what the audit requested. Views of Responsible Officials and Corrective Action : In 2023, we continued our structured process of time allocation reviews and quarterly approvals by leadership, HR, and Finance, and then in 2024, we launched our fi rst ever time study to also review and ensure time allocations were corresponding correctly with the time being spent on the grants. Name of Contact Person: Name:Julie Davis Title Chief Executive Officer Email: juliedavis@ywcatulsa.org Phone: 918-828-2346 Projected Implementation: The implementation is complete.
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the cha...
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the challenge of hiring a Payroll Specialist. In September 2022, the College outsourced “Payroll” to Paycom. We continue to develop and communicate the unique needs of our College Payroll structure and Federal and private funding sources with Paycom and the College Human Resources to ensure that employees are paid properly. As such, the Business Office is undergoing a restructure and we have identified an internal candidate to take the lead on Payroll. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Reatha Tom, Accounts Payable Specialist, Michelle Ferron-Guppy, Director – Human Resources, and Zoy Zamudio-Lane, Human Resources Generalist Planned completion date for corrective action plan: September 30, 2024
Management has reviewed and strengthened internal controls related to cost allocation, funding source tracking, and financial oversight to prevent recurrence of repeat allowable cost findings. Enhanced monitoring and documentation procedures have been implemented and will continue to be refined.
Management has reviewed and strengthened internal controls related to cost allocation, funding source tracking, and financial oversight to prevent recurrence of repeat allowable cost findings. Enhanced monitoring and documentation procedures have been implemented and will continue to be refined.
Finding 1171695 (2022-012)
Material Weakness 2022
Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk’s administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to up...
Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk’s administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to update procedures and build stronger internal controls, • developing and formalizing policies to ensure full compliance with federal grant requirements, • and improving communication between offices to ensure federal reporting is accurate and timely. Our collective commitment is to put permanent measures in place to prevent these issues from recurring and to uphold the highest level of compliance for all federal programs. County Clerk: I was not the County Clerk in office at this time. The County will comply with all aspects of grant reporting and requirements. The Officials will work together to put policies and procedures in place to ensure more accurate reporting. County Treasurer: The County Officers will work on better communication to more accurately report the SEFA funds.
Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken sign...
Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken significant steps to strengthen accounting procedures and internal controls, reinforce our invoice approval policies, and ensure all expenditures charged to Federal awards are properly reviewed and authorized prior to processing. We have enhanced our Accounts Payable workflow by implementing standardized process approval requirements, added additional leadership staffing and oversight within the Finance and Accounting team and provided targeted training to all personnel involved in invoice processing to ensure understanding of Federal cost principles and documentation standards. These corrective actions have improved our control environment since the audit period, and management is committed to continuing to develop and maintain strong financial controls and to prevent recurrence of this issue.
During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and ...
During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and reporting needs. As part of this transition, we worked closely with our new payroll provider to implement job-costing functionality that will accurately track time across grants funded programs. In addition, we have established a process requiring department leads to review and approve all timesheets prior to submission. We also partnered with our new 3rd party payroll provider to set up time allocation for salaried employees.
Finding: During the audit of the auditee's SEFA for the year ended December 31, 2022, we noted discrepancies related to incorrect identification of Assistance Listing Numbers for certain grants, as well as difficulty providing initial supporting detail for balances of expenditures for certain Federa...
Finding: During the audit of the auditee's SEFA for the year ended December 31, 2022, we noted discrepancies related to incorrect identification of Assistance Listing Numbers for certain grants, as well as difficulty providing initial supporting detail for balances of expenditures for certain Federal programs. The auditee lacks sufficient internal controls over the preparation and review of the SEFA. Specifically, there is no established process to reconcile federal expenditures reported on the SEFA to the auditee's underlying accounting records. A formal review process involving an individual independent of the preparation was not conducted to ensure the SEFA was complete and accurate before submission to the auditors. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to establish and document a formal, multilevel review process for the preparation of the SEFA. Baltimore Medical System recently hired a new grant accountant who will be responsible for the preparation of the SEFA. • The Controller will perform a detailed reconciliation of the SEFA’s data to the general ledger and supporting grant documents. • The Grant Accountant will develop a central repository that includes all grant contracts/awards and a summary document which contains the grant name, grantee, award amount and period, Assistance Listing Numbers, pass-through entity and subrecipient information. • Train relevant staff on the SEFA requirements governed by the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for the Federal Awards (2 CFR Part 200, 200.510(b)). Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO
2022-3 Assistance Listing 93.193 Urban Indian Health Services Name of Contact Person Responsible for Corrective Action: Michelle Kellum, Executive Director Corrective Actions Planned: The Organization will take steps to maintain support of payroll charges based on actual results including timesheets...
2022-3 Assistance Listing 93.193 Urban Indian Health Services Name of Contact Person Responsible for Corrective Action: Michelle Kellum, Executive Director Corrective Actions Planned: The Organization will take steps to maintain support of payroll charges based on actual results including timesheets indicating the amounts charged reflect actual staff time spent on the program. The Organization will also take the necessary steps to ensure that grant expenditure billing reports reflect actual program expenses supported by the general ledger and agree to actual amounts charged to the program. Anticipated Completion Date: These procedures will be implemented during the 1st quarter of 2025.
Finding 1168915 (2022-002)
Material Weakness 2022
Management agrees with the finding presented by the audit. Management has taken corrective actions to meet this standard. The Organization has taken corrective actions to meet this standard for FY23. These actions include the Organization implementing a grant reimbursement approval system with three...
Management agrees with the finding presented by the audit. Management has taken corrective actions to meet this standard. The Organization has taken corrective actions to meet this standard for FY23. These actions include the Organization implementing a grant reimbursement approval system with three levels of review. The controls include segregation of duties between the employee who process the data and the employees who review in order to ensure any errors are identified and remediated prior to submission to the grantor. The Staff Accountant and Shared Services team process data for reimbursement and provides the data to the Finance Manager to review and create the grant filing. Once the grant filing is prepared, the Grant Administrator reviews the grant filing and provides the completed filing to the Operations Director to review and approve prior to submission to the grantor.
Corrective Action: Management will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant accounting processes and major federal award program compliance requirements. Anticipated Completion Date: December 31, 2025
Corrective Action: Management will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant accounting processes and major federal award program compliance requirements. Anticipated Completion Date: December 31, 2025
Finding 1168824 (2022-007)
Material Weakness 2022
Condition: The District has not adopted formal controls to detect and prevent unallowable costs from being charged to grant programs. Auditor substantively tested 29 expenditures, including indirect costs, across all major programs noting that all items tested were for allowable costs. Criteria: 2 C...
Condition: The District has not adopted formal controls to detect and prevent unallowable costs from being charged to grant programs. Auditor substantively tested 29 expenditures, including indirect costs, across all major programs noting that all items tested were for allowable costs. Criteria: 2 CFR 200.303(a). Cause of Condition: Unfamiliarity with requirements stated in 2 CFR 200 of the Uniform Guidance. Effect of Condition: Effect is a state of noncompliance which may impact future grant awards or failure to identify and reject un-allowed costs charged to grant programs. Questioned Costs: none. Recommendation: Draft and adopt policies and procedures to become compliant with Uniform Guidance.Corrective Action Plan: Agency policies and procedures, including a guidance template will be clearly defined to ensure compliance with Uniform Guidance. All department managers and administrative staff will attend training and routine follow-up training on purchasing policies and procedures. A sign in sheet will be required for those attending. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 01/31/2026
Finding 1168823 (2022-006)
Material Weakness 2022
Condition: The District has not adopted written policies or procedures regarding procurements or the determination of allowable costs in accordance with the Uniform Guidance. Criteria: 2 CFR 200.302(b)(7), 2 CFR 200.318(a), and 2 CFR 200.319(d). Cause of Condition: Unfamiliarity with requirements st...
Condition: The District has not adopted written policies or procedures regarding procurements or the determination of allowable costs in accordance with the Uniform Guidance. Criteria: 2 CFR 200.302(b)(7), 2 CFR 200.318(a), and 2 CFR 200.319(d). Cause of Condition: Unfamiliarity with requirements stated in 2 CFR 200 of the Uniform Guidance.Effect of Condition: Effect is a state of noncompliance which may impact future grant awards or failure to identify and reject un-allowed costs charged to grant programs. Questioned Costs: none. Recommendation: Draft and adopt policies and procedures to become compliant with Uniform Guidance. Corrective Action Plan: Agency policies and procedures, including a guidance template will be clearly defined to ensure compliance with Uniform Guidance. All department managers and administrative staff will attend training and routine follow-up training on purchasing policies and procedures. A sign in sheet will be required for those attending. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 01/31/2026
Finding 1168821 (2022-004)
Material Weakness 2022
Condition: Support for expenditure transactions does not indicate approval from an appropriate manager with authority over the department/program. Auditor tested 57 transactions of which 17 did not include evidence of approval (excluding routine expenditures such as utility bills). Criteria: General...
Condition: Support for expenditure transactions does not indicate approval from an appropriate manager with authority over the department/program. Auditor tested 57 transactions of which 17 did not include evidence of approval (excluding routine expenditures such as utility bills). Criteria: Generally accepted control procedures and 2 CFR 200.302. Cause of Condition: Initiating procurement transactions without proper approval or failing to document that approval was obtained prior to initiating the transaction. Effect of Condition: Unapproved charges, including potential unallowable costs, may be incurred and charged to the District, including federal or state programs. Additionally, the potential exists for fraud or errors to go undiscovered and uncorrected in a timely manner. Questioned Costs: none.Recommendation: We recommend that a purchase order or purchase requisition system be devised to ensure all expenditures, including those paid for by credit cards, are approved by an appropriate manager prior to making the purchase. Corrective Action Plan: Beginning January 2026, all purchases, including credit card transactions, will require Purchase approval by the Program Manager and administration prior to purchase. A Purchase Order tracking process will be implemented in Blackbaud Financial Edge NXT by April 2026 to ensure all expenditures are properly documented. All department managers and administrative staff will attend training and routine follow-up training on purchasing policies and procedures. A sign in sheet will be required for those attending. The Financial Procedures Manual will be created and updated by June 2026 to include revised procurement approval requirements. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 06/01/2026
U.S. Department of Treasury - Coronavirus State and Local Fiscal Recovery Effort Recommendation: We recommend the County review federal guidelines to ensure that reports are identified to allow proper and timely submission. Explanation of disagreement with audit finding: There is no disagreement wit...
U.S. Department of Treasury - Coronavirus State and Local Fiscal Recovery Effort Recommendation: We recommend the County review federal guidelines to ensure that reports are identified to allow proper and timely submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County agrees and is developing a process to ensure reports are prepared and submitted. Name(s) of the contact person(s) responsible for corrective action: Donna Hillis, County Clerk Planned completion date for corrective action plan: December 31, 2025
Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one em...
Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one employee (accounts payable, payroll, balancing) and many records are not able to be located. For partial 2023-24 and 2024-25 records are now fully maintained and should be accessible for audit review. Training has been provided by the District’s Financial Consultant (payroll and accounts payable). The District Financial Consultant is reviewing payroll, processing tax and retirement payments, reviewing AP and correcting coding when necessary. The Consultant is also balancing reports and submitting monthly financial reports to the Board of Trustees.
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