Corrective Action Plans

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Finding 2022-011 Fixed Asset Inventory Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Michelle Thomas, Acting Executive Director; Program Directors; Enterprise Managers; and Rona Johnson-Murillo, Accounting Director. Action: Compile inventory listing by July 1st of each fiscal year. An...
Finding 2022-011 Fixed Asset Inventory Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Michelle Thomas, Acting Executive Director; Program Directors; Enterprise Managers; and Rona Johnson-Murillo, Accounting Director. Action: Compile inventory listing by July 1st of each fiscal year. Anticipated Completion Date: March 2026.
Finding: The Company was not able to evidence its verification that vendors paid in connection with the Coronavirus State and Local Fiscal Recovery Funds program were not suspended or debarred. Corrective Actions Taken or Planned: During the testing there was a selection of a vendor we use for Nurse...
Finding: The Company was not able to evidence its verification that vendors paid in connection with the Coronavirus State and Local Fiscal Recovery Funds program were not suspended or debarred. Corrective Actions Taken or Planned: During the testing there was a selection of a vendor we use for Nurse Staffing. We have a signed contract that was reviewed by legal which has a section that is called Compliance with Law. The Legal department manually checks for vendor to ensure they are not on the suspension and debarment list. They now log with the contract that they have verified that the vendor is not on suspension or debarment list. Baseer Tajuddin, head of Insight Legal Department, and his legal team are the responsible parties for ensuring this is remediated.
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.
This was a simple mistake in reporting the SEFA revenue instead of the expenditures. Since discovering expenditures are required this will not be an issue going forward.
This was a simple mistake in reporting the SEFA revenue instead of the expenditures. Since discovering expenditures are required this will not be an issue going forward.
Corrective Action Plan: The Organization will work with Wegner CPAs to assist with developing a written procurement policy that is in compliance with Uniform Guidance. Threshold and process for the five procurement methods. Anticipated corrective action plan completion date September 2023. Contact I...
Corrective Action Plan: The Organization will work with Wegner CPAs to assist with developing a written procurement policy that is in compliance with Uniform Guidance. Threshold and process for the five procurement methods. Anticipated corrective action plan completion date September 2023. Contact Information: For additional information regarding this finding, please contact Brandi Grayson, CEO/Founder, at (608)299-4128.
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action...
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure expenditures submitted were not already reimbursed under a separate grant. Contact person responsible for corrective action: Kevin Riley Anticipated Completion Date: 12/31/2025
Management agrees with the recommendation. Policies and procedures have been updated to make sure records are complete and accurate.
Management agrees with the recommendation. Policies and procedures have been updated to make sure records are complete and accurate.
Management agrees with the recommendation and submitted the Data Collection Form to FAC. No further action is required. within the required time period.
Management agrees with the recommendation and submitted the Data Collection Form to FAC. No further action is required. within the required time period.
Management agrees with the recommendation and will fund the security deposit account in 2026.
Management agrees with the recommendation and will fund the security deposit account in 2026.
Management agrees with the recommendation and will fund the residual receipts account during 2026.
Management agrees with the recommendation and will fund the residual receipts account during 2026.
Management agrees with the recommendation and submitted the audited financial statements to HUD. No further action is required.
Management agrees with the recommendation and submitted the audited financial statements to HUD. No further action is required.
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.
Response: Management concurs with the finding. Corrective Action Plan: Management will update procurement procedures to require pre-award sole-source justification, documented price or cost analysis, documented approvals, and retention of all required documentation in the procurement file. The Execu...
Response: Management concurs with the finding. Corrective Action Plan: Management will update procurement procedures to require pre-award sole-source justification, documented price or cost analysis, documented approvals, and retention of all required documentation in the procurement file. The Executive Director will review existing procurement files for completeness, remediate missing documentation where possible, and provide training to staff, subcontractors, and vendors involved in procurement. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by January 31, 2023.
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 documented reporting procedures that clearly define all required financial, technical, and annual reports; assign preparation and review responsibilities; and establish an internal review and approval pr...
Response: Management concurs with the finding. Corrective Action Plan: Management will implement documented reporting procedures that clearly define all required financial, technical, and annual reports; assign preparation and review responsibilities; and establish an internal review and approval process prior to submission. The Financial Analyst and Executive Director will review reports for accuracy and timeliness. Management will conduct periodic monitoring to ensure reports are submitted in accordance with award requirements. SF-425 reports will be submitted to AFRL at the same time as the Part 2 invoice for the last month of each quarter. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by March 31, 2023.
2022-003—EQUIPMENT MANAGEMENT (EQUIPMENT IDENTIFICATION/TAGGING) Response: Management concurs with the finding. Corrective Action Plan: Management will update written property and equipment procedures to require tagging of all federally funded equipment upon receipt. The Innovation Program Manager w...
2022-003—EQUIPMENT MANAGEMENT (EQUIPMENT IDENTIFICATION/TAGGING) Response: Management concurs with the finding. Corrective Action Plan: Management will update written property and equipment procedures to require tagging of all federally funded equipment upon receipt. The Innovation Program Manager will be responsible for tagging equipment, maintaining property records, and performing at least annual inventory and tagging reviews. All existing federally funded equipment currently in use, including the TVAC machine, will be reviewed and appropriately tagged. Designation of Employee Position Responsible for Meeting Deadline: Innovation Program Manager — by January 31, 2023.
2022‐002—PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS (SEFA) Response: Management concurs with the finding. Corrective Action Plan: Management will implement a documented SEFA preparation process that derives the SEFA directly from the general ledger and supporting grant schedules. A li...
2022‐002—PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS (SEFA) Response: Management concurs with the finding. Corrective Action Plan: Management will implement a documented SEFA preparation process that derives the SEFA directly from the general ledger and supporting grant schedules. A line-by-line reconciliation will be performed by the financial advisor and independently reviewed prior to finalization by the Executive Director. Documentation supporting the reconciliation and final SEFA will be retained to demonstrate accuracy and completeness. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by December 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.
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
The Village has continued to develop a course of action to ensure future Single Audit reports are completed and submitted in accordance with the requirements of 2 CFR 200.512.
The Village has continued to develop a course of action to ensure future Single Audit reports are completed and submitted in accordance with the requirements of 2 CFR 200.512.
Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control ...
Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control policies to document verification of vendors who may be listed in SAM for suspension and debarment. The College approved an updated procurement policy effective November 7, 2020, to adhere to Uniform Guidance. The College will strengthen (include) the suspension and debarment section to include a policy specific to Debarment and Suspension. Name of the contact person responsible for corrective action: Reatha Tom, Accounts Payable Specialist, and Clarissa Salhus, Finance Manager Planned completion date for corrective action plan: December 31, 2024
Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be es...
Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be established between Grant PI's and the Accounts Payable department to ensure that subrecipient payments are submitted and paid timely. These workflows will be included in the Accounts Payable procedures. 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 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 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
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