Corrective Action Plans

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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.
Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monit...
Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monitored running budget, and the Executive Director will review and approve each report prior to submission to AFRL. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by March 31, 2023.
Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9...
Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9 forms will be remediated where permissible. Management will retain evidence of completion and conduct periodic compliance reviews to ensure ongoing adherence. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by January 31, 2023.
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
Recommendation: We recommend the college retain evidence of the review of student accounts prior to disbursement of HEERF funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: No longer disbursing student HEERF fu...
Recommendation: We recommend the college retain evidence of the review of student accounts prior to disbursement of HEERF funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: No longer disbursing student HEERF funds. Discussions have taken place between Financial Aid department and Accounting staff requesting that supporting documentation is retained to show evidence that the College reviewed student accounts and eligibility prior to student disbursements. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are ...
Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are in place and trainings have been provided for Purchasing and Accounts Payable staff to ensure that all Procurement documentation is included in payment packets. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
The City will implement control procedures over receipts and transfers to ensure that all cash transactions are properly recorded and classified in the City's accounting system, in a timely manner. The City staff has since reviewed the situation to have a better understanding of how the procedures s...
The City will implement control procedures over receipts and transfers to ensure that all cash transactions are properly recorded and classified in the City's accounting system, in a timely manner. The City staff has since reviewed the situation to have a better understanding of how the procedures should be handled.
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the executive Director left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director, onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.
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.
• All outstanding accounts have been reviewed and reconciled, and variances have been· resolved and documented.
• All outstanding accounts have been reviewed and reconciled, and variances have been· resolved and documented.
• A formal monthly reconciliation schedule has been implemented for all key accounts.
• A formal monthly reconciliation schedule has been implemented for all key accounts.
· Clear responsibility and supervisory review requirements have been assigned.
· Clear responsibility and supervisory review requirements have been assigned.
• Monitoring procedures have been strengthened to ensure timeliness and documentation compliance
• Monitoring procedures have been strengthened to ensure timeliness and documentation compliance
• Future audit engagement timelines will be coordinated to align with the organization's normal financial reporting cycle to minimize risk.
• Future audit engagement timelines will be coordinated to align with the organization's normal financial reporting cycle to minimize risk.
Finding 1171698 (2022-015)
Material Weakness 2022
Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developi...
Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developing a comprehensive SOP to ensure accurate and timely tracking and reporting of federal funds, • improving communication and oversight between all county offices to ensure consistent reporting standards, • and ensuring annual compliance with federal reporting requirements. Our collective goal is to implement the policies and structures that will keep Osage County operating with the highest standard of accountability and excellence. County Clerk: I was not the County Clerk in office at this time. To correct this issue, the County plans to develop a SOP to timely and accurately track and report on federal funds. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners. County Treasurer: The County was under the understanding that once we established we were reporting as revenue loss, we would not have to submit the report annually. The final reporting was submitted prior to deadline.
Finding 1171696 (2022-013)
Material Weakness 2022
Chairman of the Board of County Commissioners: These disbursement issues originated during the prior County Clerk’s administration, but the current leadership is focused on corrective measures. Together, we are: • developing a SOP to ensure compliance with grant requirements, • establishing written ...
Chairman of the Board of County Commissioners: These disbursement issues originated during the prior County Clerk’s administration, but the current leadership is focused on corrective measures. Together, we are: • developing a SOP to ensure compliance with grant requirements, • establishing written standards of conduct to address and set clear guidelines over grant requirements, • and enhancing oversight and review to ensure all processes are fully compliant with federal regulations. Our goal is to build a consistent, transparent procurement framework that safeguards both compliance and public trust. County Clerk: I was not the County Clerk in office at this time. To correct this issue. the County plans to develop a SOP to timely and accurately track and report on federal funds. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners.
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.
Finding 1171694 (2022-011)
Material Weakness 2022
Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior Clerk’s administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of County...
Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior Clerk’s administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of County Commissioners, the new County Clerk and the other elected officials have made addressing these control weaknesses a priority. Together, we are: • strengthening county-wide policies and procedures to meet federal compliance requirements • improving communication and oversight to ensure accurate and timely federal reporting • and establishing clear standards and training for all reporting officers to prevent inaccurate or untimely reporting. Our collective goal is to build a stronger, more accountable system that ensures federal programs are managed with the highest level of integrity. County Clerk: I was not the County Clerk in office at this time. Ensure that the County has standards in place that will deter inaccurate and untimely reporting. In addition, those reporting have the knowledge and understanding to properly report. County Treasurer: The County Officers will work on better communication to more accurately report the Schedule of Expenditures of Federal Awards (SEFA) funds.
The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Managem...
The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Management acknowledges this oversight, which occurred during the implementation of a new program and at a time when staff were not fully aware that such expenditures must be reflected on the SEFA. Furthermore, certain capital expenditures paid directly through escrow were not recorded in the organization's accounting records. To remediate these issues, management has taken the following corrective actions: - Delivered targeted training to staff on the proper treatment and reporting of federally funded capital expenditures; - Updated internal closing and reporting procedures to incorporate a formal review of balance sheet activity; and - Updated internal closing and reporting procedures to incorporate a reconciliation to settlement statements when recording new property acquisitions; and - Strengthened internal controls to ensure all federally funded capital items are accurately captured in future SEFA submissions. Management is committed to maintaining compliance with federal reporting requirements and ensuring the completeness and accuracy of future SEFA filings.
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.
Finding: The Organization does have an internal procurement policy in accordance with the federal regulations, however, there appears to be a lack of controls around the documentation of following the existing procurement policies in place for all the Organization’s purchases in 2022 with federal fu...
Finding: The Organization does have an internal procurement policy in accordance with the federal regulations, however, there appears to be a lack of controls around the documentation of following the existing procurement policies in place for all the Organization’s purchases in 2022 with federal funds. there is no known monetary impact, improper expenditure of funds or questioned costs identified. However, if the Organization does not strengthen the internal controls in regard to their procurement policy, there is a possible effect on the ability of the Organization to obtain additional funding under this program if they are not following the federal regulations when it comes to procurement policies. There is a lack of review in regard to obtaining, retaining and approving documentation that support the fact that the Organization is consistently following their internal procurement policies Views of responsible officials and planned corrective actions: Management agrees with the recommendation to review policies, procedures and practices in place over the controls related to obtaining, retaining and reviewing proof of price or rate quotations from an adequate number of qualified sources. In the audit sample, many of the invoices were for Provider Agency Staffing. We only have a couple staffing agencies that we use and each are contacted when we are recruiting for a position to get proposed rate; however, it is done verbally and we could not provide proof that it was done. Going forward we will confirm rates via email and maintain the documentation supporting that we are obtaining rate quotations from an adequate number of qualified sources. • The Controller is sending out the Procurement Policy to all relevant personnel to remind them of the procedures that must be followed before making purchases greater than $10,000. • Personnel will be required to send in the quotes from the qualified sources at the time the purchase order is submitted. • The AP specialist will request support of the qualified sources prior to processing the invoices if none are sent with the invoices. Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO
Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients i...
Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients included under this program are eligible. During the compliance testing of 44 sample items, there was two instances where the Organization applied a sliding fee discount to a patient who had not submitted any documents regarding their income level or family size and we could not determine whether the patient should have been included as a sliding fee patient, and one instance where the patient had properly submitted their forms, but the Organization applied the incorrect sliding fee rate. Currently, there is no known monetary impact, improper expenditure of funds or questioned costs identified. However, if the Organization does not strengthen the internal controls in regard to the eligibility determination process, there is a possible effect on the ability of the Organization to obtain additional funding under this program if ineligible patients are being treated with grant funding. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to review policies, procedures and practices in place over the controls related to obtaining, retaining and reviewing proof of income support for patients. • Train relevant staff on the Sliding Fee eligibility process and supporting documentation requirements. Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO
Finding 2022-001 - Accurate Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review, as federal expenditures were excluded from the SEFA during fiscal year 2022. Additionally, accurate SF-425 federal reporting did not reflect the e...
Finding 2022-001 - Accurate Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review, as federal expenditures were excluded from the SEFA during fiscal year 2022. Additionally, accurate SF-425 federal reporting did not reflect the expenditures incurred for the appropriate reporting period. Lastly, the City did not submit its audit report to the federal audit clearinghouse within nine months from the year ending June 30, 2022. In conjunction with our FY2022 single audit, please see the City’s corrective action plan below: We have reviewed our current procedures related to SEFA reporting and have increased our training to ensure accurate reporting of financial information on the SEFA. We have established procedures to ensure timely reconciliation of federal expenses. We have internal controls in place to ensure that future filings are completed within the established deadlines. Expected completion date: 7/1/2024 Party Responsible: Michele Collins, Finance Director Contact Information: mcollins@tahlequah.gov
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