Corrective Action Plans

Finding 512945 (2024-005)

Significant Deficiency 2024

Brunswick County

NC

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2023-005 Name of contact person: Corrective Action: Proposed Completion Date: Priscilla Philyaw, FNS Manager A Food and Nutrition Policy refresher training on sections: 315.08, 305.06, 240.03F, 340.04, and 315.33 was completed on 9/24/2024. The topics included calculating child support and i...

Finding 2023-005 Name of contact person: Corrective Action: Proposed Completion Date: Priscilla Philyaw, FNS Manager A Food and Nutrition Policy refresher training on sections: 315.08, 305.06, 240.03F, 340.04, and 315.33 was completed on 9/24/2024. The topics included calculating child support and income, dual entitlement, work registration, and shelter expenses directly to vendors. Four additional targeted case reads per week, per worker, will be completed for six weeks. For case workers for whom continued errors are identified, additional training will be provided, and targeted case reads will be extended for four additional weeks. November 1, 2024 ELIGIBILITY - INTERNAL CONTROLS RELATED TO FNS ELIGIBILITY DETERMINATIONS

View Audit 330742

Finding 512944 (2024-004)

Significant Deficiency 2024

Brunswick County

NC

Eligibility Reporting

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-C...

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-COOPERATION WITH CHILD SUPPORT PROCEDURES Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-004 ELIGIBILITY - UNTIMELY REVIEW OF SSI TERMINATIONS Name of contact person: Corrective Action: Proposed Completion Date: A Medicaid refersher training on section MA -2320 was completed on 09/27/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 Section III - Federal Award Findings and Question Costs Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Sally Strickland, Medicaid Manager A Medicaid refresher training on section MA - 3306, 3300 and refresher on NCFAST Job Aid Removing a person from an Insurance Affordability was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom continued errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3421, 3200, 3306 was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3365 was completed on 09/30/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 November 1, 2024 November 1, 2024 Sally Strickland, Medicaid Manager

View Audit 330742

Finding 512943 (2024-003)

Significant Deficiency 2024

Brunswick County

NC

Eligibility

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-C...

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-COOPERATION WITH CHILD SUPPORT PROCEDURES Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-004 ELIGIBILITY - UNTIMELY REVIEW OF SSI TERMINATIONS Name of contact person: Corrective Action: Proposed Completion Date: A Medicaid refersher training on section MA -2320 was completed on 09/27/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 Section III - Federal Award Findings and Question Costs Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Sally Strickland, Medicaid Manager A Medicaid refresher training on section MA - 3306, 3300 and refresher on NCFAST Job Aid Removing a person from an Insurance Affordability was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom continued errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3421, 3200, 3306 was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3365 was completed on 09/30/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 November 1, 2024 November 1, 2024 Sally Strickland, Medicaid Manager

View Audit 330742

Finding 512942 (2024-002)

Significant Deficiency 2024

Brunswick County

NC

Eligibility

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-C...

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-COOPERATION WITH CHILD SUPPORT PROCEDURES Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-004 ELIGIBILITY - UNTIMELY REVIEW OF SSI TERMINATIONS Name of contact person: Corrective Action: Proposed Completion Date: A Medicaid refersher training on section MA -2320 was completed on 09/27/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 Section III - Federal Award Findings and Question Costs Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Sally Strickland, Medicaid Manager A Medicaid refresher training on section MA - 3306, 3300 and refresher on NCFAST Job Aid Removing a person from an Insurance Affordability was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom continued errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3421, 3200, 3306 was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3365 was completed on 09/30/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 November 1, 2024 November 1, 2024 Sally Strickland, Medicaid Manager

View Audit 330742

Finding 512941 (2024-001)

Significant Deficiency 2024

Brunswick County

NC

Eligibility Internal Control / Segregation of Duties

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-C...

Finding 2024-001 ELIGIBILITY - INACCURATE INFORMATION ENTRY Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-002 ELIGIBILITY - INADEQUATE REQUEST FOR INFORMATION Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-003 ELIGIBILITY - NON-COOPERATION WITH CHILD SUPPORT PROCEDURES Name of contact person: Corrective Action: Proposed Completion Date: Finding 2024-004 ELIGIBILITY - UNTIMELY REVIEW OF SSI TERMINATIONS Name of contact person: Corrective Action: Proposed Completion Date: A Medicaid refersher training on section MA -2320 was completed on 09/27/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 Section III - Federal Award Findings and Question Costs Corrective Action Plan For the Year Ended June 30, 2024 Section II - Financial Statement Findings Sally Strickland, Medicaid Manager A Medicaid refresher training on section MA - 3306, 3300 and refresher on NCFAST Job Aid Removing a person from an Insurance Affordability was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom continued errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3421, 3200, 3306 was completed on 09/30/24. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. Sally Strickland, Medicaid Manager A Medicaid refersher training on section MA - 3365 was completed on 09/30/2024. The topic included budgeting income and data entry into NCFAST. Four additional targeted case reads per week, per worker, will be completed for 4 weeks. For caseworkers for whom errors are identified, additional training will be provided, and targeted case reads will be extended four additional weeks. November 1, 2024 November 1, 2024 November 1, 2024 Sally Strickland, Medicaid Manager

View Audit 330742

Finding 512923 (2024-002)

Significant Deficiency 2024

Wake County, North Carolina

NC

Eligibility Significant Deficiency Equipment & Real Property Management

Finding 2024-002 Significant Deficiency over Eligibility (Repeat Finding); Medicaid Cluster (Medicaid), Assistance Listing Number 93. 778, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Recommen...

Finding 2024-002 Significant Deficiency over Eligibility (Repeat Finding); Medicaid Cluster (Medicaid), Assistance Listing Number 93. 778, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Recommendation: We recommend that the County train and monitor employees on the eligibility determination process. We also recommend the County review and amend current policies and procedures in place to ensure that all eligibility determination documentation is completed and retained by the County. Corrective Action Plan: The county will complete a quarterly review of errors in citizenship, resources, and documentation. For those staff identified by the targeted review with errors in these areas, supervisors will provide refresher training on Medicaid policy requirements. Additional targeted reviews will be completed monthly until the deficiencies are corrected. Proposed Completion Date: 1/31/2025 for initial quarterly review 2/28/2025 for refresher training for identified staff 7/31/2025 for additional reviews as needed for identified staff Contact Person: Kathryn Thompson, Economic Benefits Assistant Division Director

View Audit 330686

Finding 512637 (2024-002)

Significant Deficiency 2024

Lincoln Land Community College

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2024-002: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing, we noted four students out of 40 did not have documentation in their file...

2024-002: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing, we noted four students out of 40 did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be a Significant Deficiency with the Eligibility Compliance Requirement. This is a repeat finding, see Prior Year Audit Findings 2023-002. Corrective Action Plan LLCC has developed a new reporting method to capture students needing exit counseling. Responsible Person for Corrective Action Plan Alison Mills-Director of Financial Aid Implementation Date of Corrective Action Plan FY25

View Audit 330436

Finding 512636 (2024-001)

None 2024

Lincoln Land Community College

IL

Questioned Costs Student Financial Aid Eligibility

2024-001 Incorrect Pell Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing we noted one student out of forty had was not disbursed the correct Pell Grant...

2024-001 Incorrect Pell Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing we noted one student out of forty had was not disbursed the correct Pell Grant award. Based on the student’s enrollment status and need, the College over awarded the student by $925. We consider this to be an instance of noncompliance relating to the Eligibility Compliance Requirement. Corrective Action Plan This is a manual process and aid is initially reviewed during the awarding process. LLCC is working to create a report to double check aid that has been cancelled for students during an ineligible term. Responsible Person for Corrective Action Plan Alison Mills-Director of Financial Aid Implementation Date of Corrective Action Plan FY25

View Audit 330436 Questioned Costs: $1

Finding 512616 (2024-003)

Significant Deficiency 2024

Community Development Corporation of Utah

UT

Eligibility

CDCU’s UHAF Program Manager, Eleni Alatini, will update current checklists to explicitly state that Processors and Underwriters should confirm that all support matches intake allocation sheets. CDCU’s Financial Services Director, Brayan Nava and CEO, Todd Reeder, will approve the updated checklists....

CDCU’s UHAF Program Manager, Eleni Alatini, will update current checklists to explicitly state that Processors and Underwriters should confirm that all support matches intake allocation sheets. CDCU’s Financial Services Director, Brayan Nava and CEO, Todd Reeder, will approve the updated checklists. The UHAF Program Manager, Eleni Alatini, will conduct a training for all Processors and Underwriters to ensure they understand the process and will confirm with Brayan Nava and Todd Reeder once the training is complete. CDCU’s UHAF Program Manager, Eleni Alatini, will select 10% of approved files for internal monitoring every month to ensure Processors and Underwriters are following Processing and Underwriting checklists and verify income matches between allocation sheet and support. CDCU’s Financial Services Director, Brayan Nava, will review the files on a quarterly basis as well.

View Audit 330424

Finding 512526 (2024-002)

Significant Deficiency 2024

Pillar College and Subsidiaries

NJ

Reporting Student Financial Aid Eligibility

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: With new automation we have more timely notifications when students have been dropped. The Pillar Financial Aid department has updated policies and procedures to monitor the withdrawal process to ...

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: With new automation we have more timely notifications when students have been dropped. The Pillar Financial Aid department has updated policies and procedures to monitor the withdrawal process to inform the Registrar’s office, which will ensure the necessary changes to the NSLDS record are made in a timely manner. Person Responsible for Corrective Action Plan: Christine Schroeder, Assistant VP of Enrollment Services Anticipated Date of Completion: Current action

View Audit 330348

Finding 512440 (2024-003)

Significant Deficiency 2024

Dundee Community Schools

MI

Eligibility School Nutrition Programs Significant Deficiency

2024-003 – Eligibility. Auditor Description of Condition and Effect. In our sample of 40 applications from all students receiving free or reduced cost meals during the year, we noted one instance in which the point of sale (POS) system used by the District classified a student to be free, however,...

2024-003 – Eligibility. Auditor Description of Condition and Effect. In our sample of 40 applications from all students receiving free or reduced cost meals during the year, we noted one instance in which the point of sale (POS) system used by the District classified a student to be free, however, application reviewed by the District indicated ineligible to receive free and reduce meal. The student received free-price meals during the 2024 school year. As a result of this condition, the District granted free lunch to a student that did not meet the eligibility requirements. Auditor Recommendation. The district should perform a review of the POS system to match with the application to ensure only eligible students are provided with free and reduced meal. Responsible Person: Scott Leach, Superintendent and Crystal Lee, Food Service Director.Corrective Action. Management concurs with the finding. The district has already put in multiple checks and procedures for food service. The Point of Sale now has custom reports to help make sure students are in the Point-of-Sale system correctly. The Eligibility listing will be verified multiple times throughout the year. The district has set up weekly meetings with the Food Service Director, Superintendent Administrative Assistant, and the Business Manager. Anticipated Completion Date: June 30, 2025.

View Audit 330178

Finding 512338 (2024-004)

Material Weakness 2024

Ypsilanti Community Schools

MI

Questioned Costs Cash Management Eligibility

Finding 2024-004 - Material Weakness and Material Noncompliance: Eligibility and Reimbursement Request for Child and Adult Care Food Program Corrective Action: The District will collaborate with MDE Nutrition staff to complete training, staff assistance visits, and previously established corrective ...

Finding 2024-004 - Material Weakness and Material Noncompliance: Eligibility and Reimbursement Request for Child and Adult Care Food Program Corrective Action: The District will collaborate with MDE Nutrition staff to complete training, staff assistance visits, and previously established corrective actions. The Business Director and Food Service Director will schedule additional training and visits with Nutrition liaisons and MDE PAL partners. The District will implement electronic point-of-sale devices and digital filing systems to improve recordkeeping and sharing. Documented training for YCS Food Service Staff will be ongoing. District monitoring will be reinstated to ensure compliance with pre-COVID standards. Responsible Person: Director of Finance and Food Service Director

View Audit 330083 Questioned Costs: $1

Finding 512219 (2024-004)

None 2024

Texas Wesleyan University

TX

Questioned Costs Student Financial Aid Eligibility

Finding: 2024-004 Satisfactory Academic Progress Responsible Party: Douglas Cleary, Director of Financial Aid Anticipated Completion Date: July 31, 2024 The audit noted one student was awarded financial aid despite not meeting Satisfactory Academic Progress (SAP) standards. The issue stemmed from a ...

Finding: 2024-004 Satisfactory Academic Progress Responsible Party: Douglas Cleary, Director of Financial Aid Anticipated Completion Date: July 31, 2024 The audit noted one student was awarded financial aid despite not meeting Satisfactory Academic Progress (SAP) standards. The issue stemmed from a lapse in the SAP review process at the end of the Fall 2023 term, which was primarily attributed to staff turnover and insufficient training for remaining personnel. When the student did not enroll for the Spring term but later registered for the Summer 2024 session, there were no safeguards in place to prevent the system from awarding financial aid. This oversight highlighted a gap in the current process, emphasizing the need for a more robust mechanism to flag students who are not in compliance with SAP prior to awarding financial aid. In the new organizational structure, the Financial Aid Business Analyst is responsible for executing the SAP process. This individual has approximately 10 years of experience working with SAP processes. During the 2023-2024 academic year the University worked diligently to respond to a Federal Program Review from the U.S. Department of Education, (ED). As a result of the corrective actions being undertaken by the University new procedures in many areas were being drafted and implemented. A new Director of Financial Aid, with over 30 years of experience in financial aid, was hired to improve the overall student service and compliance with the Federal Title IV program. The new director commenced his duties on February 1, 2024. Since that time the University has reorganized the financial aid office by creating an Assistant Director and Financial Aid Business Analyst position who have increased the expertise and overall years of financial aid experience. A leadership team including the Director of Financial Aid, Registrar, Director of Student Accounts, Associate Provost, Provost and Vice President for Finance and Administration was created in January 2024 and meet bi-weekly to discuss Title IV compliance topics, process improvement and customer service. Most of the Financial Aid team’s time in the spring and summer was spent working on the new FAFSA. The team has redirected their efforts in training, standardizing, documenting and improving processes to ensure Title IV compliance and better serve students.

View Audit 329972 Questioned Costs: $1

Finding 512214 (2024-003)

None 2024

Texas Wesleyan University

TX

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding: 2024-003 Verification Responsible Party: Douglas Cleary, Director of Financial Aid Anticipated Completion Date: October 17, 2024 The auditors identified two issues related to verification of financial aid data supplied on the FAFSA by students. Both findings were from the fall of 2023 and i...

Finding: 2024-003 Verification Responsible Party: Douglas Cleary, Director of Financial Aid Anticipated Completion Date: October 17, 2024 The auditors identified two issues related to verification of financial aid data supplied on the FAFSA by students. Both findings were from the fall of 2023 and in both cases a secondary review was completed and still was not accurately completed. The Office of Financial Aid developed and implemented a comprehensive Business Process Guide (BPG) on October 17, 2024. The guide is aimed at ensuring that all required fields within the verification process are meticulously reviewed and corrected as needed. This guide serves as a crucial resource for staff involved in the financial aid verification process, outlining best practices and standard procedures to maintain compliance and accuracy. The verification correction process follows a two-step approach: 1. Initial Review and Correction: Staff members are required to conduct a thorough review of the required data fields. This involves checking the required ISIR data fields against other supplemental information to identify any discrepancies or inaccuracies. Once identified, corrections are made to ensure that all data aligns with federal and institutional requirements. 2. Final Confirmation and Awarding: After the necessary corrections are implemented, a secondary review is conducted by the Assistant Director to confirm that the adjustments are accurate. This ensures that students receive the correct financial aid awards based on updated and verified information. To maintain transparency, accountability, and an adequate documentation trail. It is imperative that any comments added to student accounts are detailed and include pertinent information regarding the verification process. This documentation serves as a record of the actions taken and aids in future audits and reviews. The Assistant Director of Financial Aid is a very experienced financial aid professional and holds NASFAA certifications in Verification, R2T4, Student Eligibility, Direct Loans and Professional Judgement. The Assistant Director plays a pivotal role in the verification process, being responsible for updating the BPG to reflect any changes in regulations or best practices. Additionally, the Assistant Director will lead training sessions for staff members to ensure they are well-versed in the verification procedures outlined in the BPG. Ongoing training will be provided as needed to accommodate changes in policies or technologies. By implementing this structured approach to verification corrections, the University aims to enhance the accuracy of financial aid processing and improve the overall student experience.

View Audit 329972

Finding 512130 (2024-005)

Significant Deficiency 2024

Connors State College

OK

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Student Financial Assistance Cluster- Assistance Listing No. 84.063, Finding: The College under-awarded funds for the Pell Grant. Context: During our testing, we identified 2 out of 40 students were awarded and disbursed less Pell funds than should have been awarded based on the 23-24 Pell payment s...

Student Financial Assistance Cluster- Assistance Listing No. 84.063, Finding: The College under-awarded funds for the Pell Grant. Context: During our testing, we identified 2 out of 40 students were awarded and disbursed less Pell funds than should have been awarded based on the 23-24 Pell payment schedule. The Pell payment schedule considers the cost of attendance, the student's Expected Family Contribution and the enrollment status of the student. Cause: Student was initially not disbursed Pell funds due to electronic terms & conditions not being completed. However, when the student completed this requirement in the Spring, Pell was not disbursed for the Fall semester Recommendation: We recommend the College review its current procedures for awarding Title IV funds and implement any changes necessary to ensure federal funds are awarded and disbursed in accordance with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This is due to a loss of knowledge due to turnover within the FA department. Moving forward, knowledge procedures and knowledge will be disseminated to all FA staff to ensure there are no gaps causing a reoccurring issue. Name(s) of the contact person(s) responsible for corrective action: Tina Ballinger Planned completion date for corrective action plan: 11/01/2024

View Audit 329878 Questioned Costs: $1

Finding 512121 (2024-004)

Significant Deficiency 2024

Connors State College

OK

Matching / Level of Effort / Earmarking Student Financial Aid Eligibility § 200.303

Student Financial Assistance Cluster- Assistance Listing No. 84.007, 84.038, 84.063, 84.268 Finding: The College did not properly have documentation of exit counseling notification. Context: During our testing of 40 students, we identified 5 students that did not have documentation of exit counselin...

Student Financial Assistance Cluster- Assistance Listing No. 84.007, 84.038, 84.063, 84.268 Finding: The College did not properly have documentation of exit counseling notification. Context: During our testing of 40 students, we identified 5 students that did not have documentation of exit counseling notification. Cause: The College did not have proper procedures in place to ensure that notification of required exit counseling was sent to applicable students. Recommendation: We recommend the College review reporting processes to ensure all students that require exit counseling receive it in a timely manner Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This is due to a loss of knowledge due to turnover within the FA department. Moving forward, knowledge about loan exit counseling will be disseminated to all FA staff to ensure there are no gaps causing a reoccurring issue. Name(s) of the contact person(s) responsible for corrective action: Tina Ballinger Planned completion date for corrective action plan: 12/15/2024

View Audit 329878

Finding 512114 (2024-003)

Material Weakness 2024

Lutheran Social Services of South Dakota

SD

Questioned Costs Eligibility Material Weakness § 200.303

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: a. One instance in which a family was overpaid for one month due to the family obtaining employment...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: a. One instance in which a family was overpaid for one month due to the family obtaining employment. b. One instance in which a family was underpaid for one month based upon their family size and eligibility for the month. Additionally, documentation was not retained to support one month's redetermination of eligibility and check copies for two months were not retained to support the payment to the family. c. Three instances in which a family was underpaid based upon their family size and eligibility for the month. d. One instance in which a check was written to a family who out-migrated from the state of South Dakota and the family did not cash the check; however, the expenses remained to be charged under the Refugee Cash Assistance program. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: a. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate the proration when a client obtains employment during the month. b. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate family size and eligibility. Additionally, document retention requirements will be reviewed with staff. c. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate family size and eligibility. d. The procedures will be reviewed with staff for removing a client from the program, and notifying appropriate staff to void checks. LSS also implemented a new software program during the fiscal year to make the review process more efficient, and less reliant on manual processes. Checks and balances will be integrated into the software, allowing for electronic review of files. The software will also automate some of the ongoing documentation requirements. Anticipated Completion Date: December 31, 2024

View Audit 329857 Questioned Costs: $1

Finding 512065 (2024-001)

Significant Deficiency 2024

Eastern Oregon University

OR

Questioned Costs Matching / Level of Effort / Earmarking Student Financial Aid § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend that the University review their awarding procedures and implement procedures to ensure direct loans are awarded within student eligibility. Explanation of disagreement with audit finding: There is no d...

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend that the University review their awarding procedures and implement procedures to ensure direct loans are awarded within student eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office (FAO) plans to do more expansive training for the Financial Aid Administrators upon hire. FAO is exploring the option of National Association of Student Financial Aid Administrators training certification for a Need Analysis credential. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert Planned completion date for corrective action plan: February 28, 2025

View Audit 329796 Questioned Costs: $1

Finding 511960 (2024-001)

Material Weakness 2024

Comprehend Properties Inc.

KY

Eligibility HUD Housing Programs

The property manager will be responsible for the calculation. The income verification documentation will be reviewed and signed off by the property manager supervisor which is the COO for Comprehend.

View Audit 329691

Finding 511937 (2024-003)

Significant Deficiency 2024

Lincoln University of the Commonwealth System of Higher Education

PA

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing Number 84.007, 84.063, 84.268 Recommendation: We recommend that the University review its procedures related to updating the Eligibility and Certification Approval Report in a timely fashion. Explanation of disagreement with audit finding: ...

Student Financial Assistance Cluster – Assistance Listing Number 84.007, 84.063, 84.268 Recommendation: We recommend that the University review its procedures related to updating the Eligibility and Certification Approval Report in a timely fashion. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: University will review which individuals are listed on the ECAR. Upon learning of their departure, the University will update ECAR immediately. Name(s) of the contact person(s) responsible for corrective action: H. Jonas Javier Planned completion date for corrective action plan: November 4, 2024

View Audit 329658

Finding 511747 (2024-017)

Significant Deficiency 2024

Nevada System of Higher Education

NV

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility § 200.303

UNLV – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: While there were no specific instances noted regarding eligibility issues, the UNLV Office of Sponsored Programs r...

UNLV – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: While there were no specific instances noted regarding eligibility issues, the UNLV Office of Sponsored Programs recognizes the importance of documentation through the COSO internal control framework and will ensure the controls are continued, effective immediately. UNLV OSP will continue to enhance the documentation for the administrative management of programs to review and determine eligibility of participants per the requirements of the project, and those employees will be reminded of the importance of evidencing their reviews. • How compliance and performance will be measured and documented for future audit, management and performance review: Verification of eligibility will continue to be performed as required, with enhanced documentation. If escalation is needed, the employee will seek guidance from a supervisor and properly document. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: UNLV Office of Sponsored Programs Executive Director will be responsible for communicating the importance of enhanced documentation to the designated employees responsible for eligibility. UNR – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: Staff, independent of the preparer, will review and log each eligibility determination. • How compliance and performance will be measured and documented for future audit, management and performance review: A log will be maintained listing the review date and reviewer name for each determination. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The Program Director, who is a Head Start Program Principal Investigator (PI), is responsible for remediation of this finding. Name of contact person responsible for corrective action plan: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu

View Audit 329596

Finding 511743 (2024-012)

Material Weakness 2024

Nevada System of Higher Education

NV

Student Financial Aid Reporting Special Tests & Provisions

NSU – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: To ensure accurate and timely reporting of changes in student enrollment status to the National Student Clearinghou...

NSU – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: To ensure accurate and timely reporting of changes in student enrollment status to the National Student Clearinghouse (NSC), Nevada State University (NSU) will enhance its internal controls by implementing the following measures: o Continue the current bi-weekly enrollment reporting schedule. o Set bi-weekly calendar reminders to ensure timely reporting, supplementing NSC notifications. o Establish end-of-term calendar reminders specifically for reporting graduated statuses promptly. o Work closely with the NSC to identify any students included in submitted enrollment reports whose statuses were not updated within the NSC or National Student Loan Data System (NSLDS), ensuring they are addressed even if they do not appear in the reject file. • How compliance and performance will be measured and documented for future audit, management and performance review: To ensure ongoing compliance and performance in reporting changes in student enrollment status, Nevada State University (NSU) will implement the following measures for tracking and documentation: o NSU will conduct monthly reviews of enrollment status reports to verify the accuracy and timeliness of submissions to the National Student Clearinghouse (NSC). o Detailed logs of all enrollment status submissions and NSC notifications will be maintained, including timestamps and submission confirmations, to serve as an audit trail for internal and external reviews. o Periodic internal audits will be scheduled to assess adherence to the bi-weekly and end-of-term reporting schedule, with results documented for management review. o Key performance indicators (KPIs) will be established, such as the percentage of on-time reports and the accuracy rate of enrollment status updates. These metrics will be reviewed quarterly by management. o Any discrepancies identified during audits will be addressed promptly, and corrective actions will be documented for future reference and performance evaluations. o NSU will compile annual compliance reports summarizing audit results, corrective actions, and performance metrics, which will be available for future audits and management reviews. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The Registrar's Office holds primary responsibility for accurate and timely enrollment status reporting. The Registrar will oversee compliance with internal controls including the bi-weekly and end-of-term reporting schedules. Additional oversight will be conducted by the Provost and Vice President of Academic Affairs. Name of contact person responsible for corrective action plan: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu

View Audit 329596

Finding 509741 (2024-001)

Material Weakness 2024

Westfield Washington Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

Finding 2024-001 – Child Nutrition Cluster – Eligibility Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: School corporation personnel w...

Finding 2024-001 – Child Nutrition Cluster – Eligibility Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: School corporation personnel will conduct an annual review of the income eligibility guidelines used by the food service software. The review will ensure that the guidelines are current, accurate, and consistent with federal and state requirements. The results of the review will be documented, and any necessary updates or changes will be implemented promptly. Anticipated Completion Date: November 13, 2024

View Audit 329409

Finding 509736 (2024-001)

Significant Deficiency 2024

Generations Family Health Center, Inc.

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Generations Family Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2024 The findings from the June 30, 2024 ...

To Health Resources and Services Administration Generations Family Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2024 The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2024.001 - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken A discrepancy was found in the sliding fee information of a selection in the audit process. The information collected by the patient intake system was not properly entered into the practice management system for a selection. Action: A periodic sliding fee scale audit across all sites will be conducted to compare the information in the patient intake system with the data in the practice management system. If there are any question regarding this plan, please e-mail Debra Daviau Savoie at DSavoie@genhealth.org.

View Audit 329406

Finding 509721 (2024-001)

None 2024

Jacksonville Towers, INC

FL

HUD Housing Programs Eligibility Reporting

Oversight Agency for Audit, Jacksonville Towers, Inc., respectfully submits the following corrective action plan for the year ended March 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audi...

Oversight Agency for Audit, Jacksonville Towers, Inc., respectfully submits the following corrective action plan for the year ended March 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: April 1, 2023 through March 31, 2024 The findings from the March 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Rental Housing Projects, ALN 14.155 Recommendation: The Project should implement procedures to ensure that tenant eligibility is verified, tenant files are properly maintained, and tenant signatures are obtained in a timely manner. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and included in monthly report procedures.

View Audit 329376

Corrective Action Plans

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