Corrective Action Plans

Finding 539714 (2024-012)

Significant Deficiency 2024

State of Mississippi Institutions of Higher Learning

MS

Student Financial Aid Reporting Significant Deficiency

Finding Reference: 2024-012 - SFA Reporting (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: Jackson State University has established a formalized procedure, effective immediately, to ensure the accurac...

Finding Reference: 2024-012 - SFA Reporting (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: Jackson State University has established a formalized procedure, effective immediately, to ensure the accuracy and compliance of the annual Fiscal Operations Report and Application to Participate (FISAP). As part of this process, a FISAP Review Committee will be created to oversee the review of the FISAP and all supporting documentation at least three weeks before the official submission deadline. The FISAP will be prepared by the Executive Director of Student Financial Aid Services and Scholarships, who will also gather and compile all necessary supporting documentation. This completed report, along with all relevant data, will then be submitted to the FISAP Review Committee for thorough examination. The committee will verify the accuracy of all figures and ensure that the supporting documents meet FISAP compliance requirements. Submission of the FISAP will only proceed once the FISAP Review Committee has reached a consensus confirming the accuracy and completeness of the report. This structured review process will help safeguard against errors, enhance compliance, and ensure that JSU meets all federal reporting standards. Estimated Completion Date: September 1, 2025

View Audit 350191

Finding 539713 (2024-011)

Significant Deficiency 2024

State of Mississippi Institutions of Higher Learning

MS

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency § 200.1 § 200.302 § 200.307

Finding Reference: 2024-011 - Program Income, Ryan White (UMMC) Responsible Official: Mustafa Khawaja, Interim Director of Post-Award Corrective Action Planned: Based on feedback received from a Sponsor-led site visit in 2024, UMMC practices and policies are appropriately aligned with the intent of ...

Finding Reference: 2024-011 - Program Income, Ryan White (UMMC) Responsible Official: Mustafa Khawaja, Interim Director of Post-Award Corrective Action Planned: Based on feedback received from a Sponsor-led site visit in 2024, UMMC practices and policies are appropriately aligned with the intent of the program. UMMC will make efforts to ensure that all practices and policies are clearly documented and evaluated periodically. Estimated Completion Date: June 30, 2025

View Audit 350191

Finding 539689 (2024-007)

None 2024

State of Mississippi Institutions of Higher Learning

MS

Questioned Costs Student Financial Aid Internal Control / Segregation of Duties

Finding Reference: 2024-007 - SFA Eligibility (ASU) Responsible Official: Juanita Edwards, Director of Financial Aid Corrective Action Planned: ASU disburses aid to students’ accounts once the student has completed registration. The student was enrolled and eligible for the Pell grant. The student h...

Finding Reference: 2024-007 - SFA Eligibility (ASU) Responsible Official: Juanita Edwards, Director of Financial Aid Corrective Action Planned: ASU disburses aid to students’ accounts once the student has completed registration. The student was enrolled and eligible for the Pell grant. The student had not completed registration, so Pell was not disbursed. Moving forward ASU will review all student accounts to ensure students have completed the registration process. If they have not completed registration timely, they will be notified. Once notified and registration is complete, Title IV funds will be disbursed to the students’ accounts. Checks and balances have been reviewed and implemented to ensure the process is completed timely. Estimated Completion Date: June 30, 2025

View Audit 350191 Questioned Costs: $1

Finding 539687 (2024-005)

Material Weakness 2024

State of Mississippi Institutions of Higher Learning

MS

Student Financial Aid Material Weakness Reporting

Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (ASU) Responsible Official: Kisha Bond, Registrar Corrective Action Planned: ASU must report enrollment status for students in the NSLDS database within a 60-day window. ASU reported the enrollment status for the ...

Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (ASU) Responsible Official: Kisha Bond, Registrar Corrective Action Planned: ASU must report enrollment status for students in the NSLDS database within a 60-day window. ASU reported the enrollment status for the students but not within 60 days. Moving forward, ASU will monitor the activity for the NSLDS database and submit student enrollment data on a timely basis. Estimated Completion Date: August 29, 2025 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (JSU) Responsible Official: Ms. Lakesha Tubbs, Registrar Corrective Action Planned: Jackson State University will implement a multi-tiered enrollment reporting schedule to enhance accuracy and prevent certification and enrollment reporting errors. Effective immediately, JSU will submit an initial enrollment reporting file to the National Student Clearinghouse at the beginning of each term. Additionally, two subsequent enrollment reports will be submitted—one at midterm and another within ten (10) days of final grade publication at the end of the term. To ensure consistency, transparency, and alignment across university departments, JSU will establish an Enrollment Reporting Oversight Committee composed of representatives from key university offices. This committee will convene quarterly throughout the academic year to review enrollment reporting processes, address potential discrepancies, and implement best practices. By fostering collaboration amongst stakeholders, JSU will ensure compliance, accuracy, and efficiency in enrollment reporting. Estimated Completion Date: May 9, 2025 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (MSU) Responsible Official: Emily Shaw, University Registrar Corrective Action Planned: In addition to reporting in a timely manner to National Student Clearinghouse, MSU will also begin to monitor NSC’s reports to NSLDS. Estimated Completion Date: June 15, 2025 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (MVSU) Responsible Official: Jeffrey Loggins, Director of Student Records Corrective Action Planned: The Office of Student Records will review the schedule submission dates for enrollment reporting to the National Student Clearinghouse to ensure compliance with certifying student enrollment within 60-day timeframe from program enrollment effective date. Additionally, enrollment reporting data will be carefully reviewed in an effort to avoid future enrollment errors. Moreover, this may include adding an additional date to report enrollment data during semesters. Estimated Completion Date: February 15, 2026 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (UMMC) Responsible Official: Emily Cole, Executive Director Office of Enrollment Management Corrective Action Planned: As an internal control measure, the Office of Enrollment Management has identified two individuals to verify all enrollment changes are appropriately captured in the National Student Loan Data System (NSLDS) within the 60-day time period. The Senior Record Specialist and Senior Enrollment Data Specialist will review pertinent records in the NSLDS monthly to verify all information has been correctly conveyed from the National Student Clearinghouse System. Estimated Completion Date: Effective immediately

View Audit 350191

Finding 539685 (2024-003)

Significant Deficiency 2024

State of Mississippi Institutions of Higher Learning

MS

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

Finding Reference: 2024-003 - SFA COD Reporting (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU reconciles Pell and federal direct student loans to COD monthly. The reconciliation is done timely, and ASU will continue to reconcile and pr...

Finding Reference: 2024-003 - SFA COD Reporting (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU reconciles Pell and federal direct student loans to COD monthly. The reconciliation is done timely, and ASU will continue to reconcile and provide evidence of review. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships; Ms. Lakesha Tubbs, Registrar; Adrienne Walls, Bursar Corrective Action Planned: In previous years, Jackson State University has extended the purge and registration dates to better serve a high number of students from underrepresented communities and low-income backgrounds, ensuring that they have the opportunity to complete the enrollment process. However, this practice has led to inaccurate reporting of enrollment dates. Moving forward, Jackson State University will work with new, continuing, and readmit students beginning in April 2025 through the start of the Fall 2025 semester on August 18, 2025, to ensure all enrollment materials are completed before the beginning of each term. As part of this effort, Jackson State University has redesigned its new student orientation process with the goal of ensuring students are completely registered before arriving on campus for the fall semester. Within this new model, a dedicated position has been created for First-Time Freshmen to establish proactive outreach and education regarding costs to students and families. The redesigned orientation process places a strong emphasis on First-Time Freshmen, guaranteeing they receive the necessary guidance and support to successfully transition into college life. Additionally, the university will enforce enrollment deadline dates to prevent inaccurate enrollment data and eliminate errors in disbursement records. In addition to enhancing the student enrollment process, JSU is also taking steps to strengthen financial accountability. Furthermore, Jackson State University’s Financial Aid Office, in coordination with its Business Office, will begin holding regularly scheduled reconciliation meetings at the end of each month. These meetings will ensure that the amounts disbursed on both sides align and that figures from both departments match what has been drawn down and either paid out or returned to the U.S. Department of Education Common Origination and Disbursement (COD). Both departments will also utilize an institutional reconciliation document to add another layer of control and prevent errors. These strategic improvements reflect Jackson State University’s ongoing commitment to compliance, operational efficiency, and student success. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The internal control procedures will initiate a reconciliation of disbursement dates against COD data. Estimated Completion Date: September 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (UMMC) Responsible Official: Davita Weary, Director of Student Financial Aid Corrective Action Planned: Reconciliations will be reviewed with Kelly Dismuke, Director of Finance Operations, on a monthly basis. Estimated Completion Date: March 26, 2025 Finding Reference: 2024-003 - SFA COD Reporting (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: USM reconciles Pell and DL monthly. Copies of reconciliations are saved in a shared drive and can be made available upon request. The reconciliations will be reviewed on a monthly basis by the Financial Aid Assistant Director (Alanna McDonald) and Director (David Williamson), and the Bursar (Barbara Madison) when necessary. Estimated Completion Date: March 17, 2025

View Audit 350191

Finding 539678 (2024-008)

Significant Deficiency 2024

State of Mississippi Institutions of Higher Learning

MS

Special Tests & Provisions Student Financial Aid Significant Deficiency

Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: The Jackson State University Division of Financial Aid has implemented a co...

Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: The Jackson State University Division of Financial Aid has implemented a comprehensive training initiative to strengthen compliance, improve accuracy, and enhance staff proficiency in federal student aid verification. As of May 7, 2024, ongoing training has commenced for all financial aid staff on the 2024-2025 verification process and required documentation. Additionally, beginning April 4, 2025, the department will launch continuous training on verification procedures and Federal Student Aid compliance to ensure staff remains informed of regulatory updates and best practices. To further enhance accuracy and accountability, the department will collaborate with the Department of Information Technology (IT) to develop internal error reports that proactively identify discrepancies in student records. An internal checklist will also be implemented to ensure that each student selected for verification by the U.S. Department of Education has submitted all required documentation. This checklist must be reviewed and signed off by the Executive Director of Student Financial Aid Services and Scholarships before final processing. As part of the department’s transition to a more automated verification process, JSU will integrate Campus-Logic, powered by Ellucian, to streamline operations and reduce manual errors. Comprehensive training sessions will be conducted to ensure financial aid staff are proficient in using the platform. Additionally, an internal checklist within Campus-Logic will be established to facilitate structured review and compliance tracking. A final verification review will be conducted by the Executive Director of Student Financial Aid Services and Scholarships to uphold accuracy and federal compliance, ultimately mitigating errors and improving audit outcomes. Estimated Completion Date: December 19, 2025 Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The verification process will ensure all student data is accurate and corrected by staff. Estimated Completion Date: September 30, 2025

View Audit 350191

Finding 539677 (2024-006)

Significant Deficiency 2024

State of Mississippi Institutions of Higher Learning

MS

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

Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (ASU) Responsible Official: Charlette Mock, Director of Accounting Corrective Action Planned: ASU uses a servicer to deliver ...

Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (ASU) Responsible Official: Charlette Mock, Director of Accounting Corrective Action Planned: ASU uses a servicer to deliver credit balance to students. The contract with the servicer should have been uploaded to the Dept of Ed database. Since the audit finding, the contract has been uploaded. ASU will upload the contract timely going forward. Estimated Completion Date: Effective Immediately Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (MVSU) Responsible Official: Mrs. Brittney Manuel-Carpenter, Account Receivable Supervisor Corrective Action Planned: MVSU acknowledged the findings of reference 2024-06 SFA-Special Test- Using a Servicer to Deliver Title IV Credit Balances. MVSU acknowledges that the servicer contract is uploaded to the Department of Education database and is available for viewing. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: University will contact the Department of Education Cash Management to correct the URL link. While the link was broken on the Cash Management site it was active on the USM Business Services website: https://www.usm.edu/business-services/refunds.php and is continually maintained on their site. Estimated Completion Date: April 1, 2025

View Audit 350191

Finding 539676 (2024-004)

Significant Deficiency 2024

State of Mississippi Institutions of Higher Learning

MS

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

Finding Reference: 2024-004 - SFA Special Tests and Provisions - GLBA (MVSU) Responsible Official: Dameon A. Shaw, Vice President for Information Technology Corrective Actions Planned: 1. Develop a Comprehensive Information Security Program to ensure MVSU has a full information security program that...

Finding Reference: 2024-004 - SFA Special Tests and Provisions - GLBA (MVSU) Responsible Official: Dameon A. Shaw, Vice President for Information Technology Corrective Actions Planned: 1. Develop a Comprehensive Information Security Program to ensure MVSU has a full information security program that addresses all 7 required elements of the GLBA regulations: • Review GLBA Requirements: Conduct a thorough review of the Gramm-Leach-Bliley Act (GLBA) regulations to understand the 7 required elements. - Completed • Gap Analysis: A gap analysis has been performed to identify missing elements in the current information security program. - Completed • Program Development: Develop and implement policies and procedures to address the identified gaps. This includes administrative, technical, and physical safeguards. - In Progress • Training: Provide training to staff on the new policies and procedures to ensure compliance and proper implementation. - Planning • vCISO Support: Leverage the expertise of the newly hired virtual Chief Information Security Officer (vCISO) to guide the development and implementation of the information security program. - In Progress 2. Conduct a Comprehensive Risk Assessment to identify and address significant gaps in the risk assessment process: • Risk Assessment Framework: Establish a risk assessment framework that aligns with GLBA requirements. - In Progress • Identify Risks: Identify potential risks to the confidentiality, integrity, and availability of customer information. – In Progress • Evaluate Controls: Assess the effectiveness of existing controls and identify areas for improvement. – In Progress • Mitigation Plan: Develop a risk mitigation plan to address identified vulnerabilities and implement appropriate controls. - Planning • vCISO Support: Utilize the vCISO's expertise to ensure a thorough and effective risk assessment process. – In Progress 3. Monitoring and Continuous Improvement to ensure ongoing compliance and continuous improvement of the information security program: • Regular Audits: Conduct regular audits to ensure compliance with GLBA regulations and the effectiveness of the information security program. – Planning • Feedback Mechanism: Establish a feedback mechanism to gather input from staff and stakeholders on the effectiveness of the program. - Planning • Update Policies: Periodically review and update policies and procedures to address emerging threats and changes in regulations. – In Progress • vCISO Support: Engage the vCISO in monitoring and continuous improvement efforts to maintain high standards of information security. – In Progress 4. Reporting and Accountability to ensure accountability and transparency in the implementation of the corrective action plan: • Assign Responsibility: Assign responsibility for the implementation of the corrective action plan to a dedicated team or individual. - Planning • Progress Reports: Provide regular progress reports to senior management and stakeholders on the implementation of the corrective action plan. - Planning • Documentation: Maintain thorough documentation of all actions taken to address the identified issues. - Planning • vCISO Support: Include the vCISO in reporting and accountability processes to ensure expert oversight and guidance. – In Progress By following this corrective action plan and leveraging the expertise of the vCISO, MVSU can address the deficiencies in its information security program and risk assessment process, ensuring compliance with GLBA regulations and protecting customer information effectively. Estimated Completion Date: November 30, 2025

View Audit 350191

Finding 539675 (2024-002)

Material Weakness 2024

State of Mississippi Institutions of Higher Learning

MS

Questioned Costs Student Financial Aid Special Tests & Provisions

Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU will ensure that post withdrawal aid that could have been disbursed will be disbursed timely unless...

Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU will ensure that post withdrawal aid that could have been disbursed will be disbursed timely unless the student requests otherwise. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: Jackson State University has examined the error and has implemented targeted training on the Return of Title IV (R2T4) process. This training focuses on accurately determining break days and performing the required calculations to ensure precision and compliance. To reinforce these efforts, the university will continue to provide quarterly training and cross-training opportunities for staff, ensuring a comprehensive understanding of R2T4 policies and procedures. To further strengthen accuracy, an additional internal review process has been established within the financial aid office. This review will be conducted by the Executive Director of Financial Aid, who will oversee calculations until the responsibility is designated to another team member with demonstrated expertise in R2T4 processing. These corrective measures will enhance the accuracy of R2T4 calculations, ensure compliance with federal regulations, and improve overall financial aid operations at Jackson State University. Estimated Completion Date: May 2, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (MSU) Responsible Official: Lori Ball Executive Director for Financial Aid and Scholarship Corrective Action Planned: Our interpretation of the regulation was that if classes were held on weekends before or after the 5-day break, the weekend days were not counted, only the week itself (Monday- Friday) and the weekend afterwards. Classes started back the next Monday so we used 7 days. If we do not have classes on Saturday before spring break, we are now counting 9 days. Estimated Completion Date: March 15, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The internal control procedures have been updated to incorporate a nine-day break. The refund of funds to the Department of Education will be processed upon completion of the necessary calculations. Estimated Completion Date: September 30, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (UM) Responsible Official: Mr. Eduardo Prieto, Vice Chancellor for Enrollment Management Corrective Action Planned: The University of Mississippi’s Office of Financial Aid has an existing process for next-level supervisor review of all Return of Title IV (R2T4) calculations. To further strengthen compliance, future R2T4 reviews will also include any documentation used to determine the date of withdrawal. While it is believed that communication with instructors was accurate, messaging will be refined to clarify which activities cannot be used to document academic engagement (e.g., simply logging into the online system). Additional scrutiny will be applied when determining the last date of attendance for online courses, and instructors will be contacted for clarification as needed. The Office of Financial Aid has also established a unit to enhance compliance through internal reviews of various processes, including R2T4. Although not all R2T4 calculations will be selected for examination, sample evaluations will provide an additional level of oversight. Additionally, a transition to Ellucian’s Banner system is planned for the 2026-2027 academic year, requiring instructors to report the last date of attendance for all F grades at the time of grade entry. This change will help minimize ambiguity regarding unofficial withdrawals. Estimated Completion Date: April 1, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (UMMC) Responsible Official: Coralisa Williams, Senior Financial Aid Advisor Corrective Action Planned: Processing procedure has been updated to state the use of the “last date in class” from the academic calendar published in the UMMC Bulletin to ensure consistent and correct processing of R2T4. Estimated Completion Date: Effective immediately (has reviewed current R2T4 for accuracy) Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: The university included the Friday commencement day as last day of the term. Our reasoning is that some students are still completing assignments, tests, and class projects through the day of commencement. The financial aid office will verify the number of class days with the registrar office before each semester to ensure all class days are included in the award period. The student with the possible post-withdrawal disbursement withdrew prior to our census and all institutional charges were reversed and we could not verify that the student actually attended any of their classes. Effective February 3, 2025, institutions are exempt from performing an R2T4 calculation in this situation. Amend § 668.22(a)(2)(ii)(A)(6) to exempt institutions from performing an R2T4 calculation if: (1) a student is treated as never having begun attendance; (2) the institution returns all title IV, HEA assistance disbursed to the student for that payment period or period of enrollment; (3) the institution refunds all institutional charges to the student for that payment period or period of enrollment; and (4) the institution writes off or cancels any payment period or period of enrollment balance owed by the student to the institution due to the institution's returning of title IV, HEA funds to the Department. Going forward, USM intends to not perform R2T4 calculations for students that meet one of the above exemptions. Other possible post withdrawal disbursement will be tracked, and communication will be sent to students eligible once they are identified and calculated upon withdrawal. Estimated Completion Date: March 17, 2025

View Audit 350191 Questioned Costs: $1

Finding 539670 (2024-010)

Significant Deficiency 2024

State of Mississippi Institutions of Higher Learning

MS

Questioned Costs Eligibility Significant Deficiency

Finding Reference: 2024-010 - Eligibility (Board Office) Responsible Official: Dr. Casey Prestwood, Associate Commissioner for Academic and Student Affairs Corrective Action Planned: An evaluation form was developed and implemented to be used with each applicant review as a checklist of requirements...

Finding Reference: 2024-010 - Eligibility (Board Office) Responsible Official: Dr. Casey Prestwood, Associate Commissioner for Academic and Student Affairs Corrective Action Planned: An evaluation form was developed and implemented to be used with each applicant review as a checklist of requirements. In addition, there is a second layer of review of all approved applicants’ eligibility prior to requesting disbursement of funds. An outside CPA firm was contracted in May 2024 to perform the second layer of review of each approved applicant before disbursement, to review all disbursement prior to that date in the current grant cycle, and to provide guidance on internal controls. An additional staff person to assist with grant awarding and programmatic operations was hired in August 2024. Estimated Completion Date: August 2024

View Audit 350191 Questioned Costs: $1

Finding 539640 (2024-005)

Significant Deficiency 2024

Nbcc

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

xiii. Management Response and Corrective Action Plan: One of the individuals tested was identified as not being enrolled in the audited grant during the audit period. This is correct. The individual was exited from the program in the previous audit period and written documentation was uploaded to d...

xiii. Management Response and Corrective Action Plan: One of the individuals tested was identified as not being enrolled in the audited grant during the audit period. This is correct. The individual was exited from the program in the previous audit period and written documentation was uploaded to demonstrate this. However, the case manager neglected to exit the individual from HMIS during the previous audit period. This has been corrected. No services or funds were provided to this individual following their exit from the program. Our program has a good track record of data compliance and we expect this was an exception and not the rule. Program management will review and train staff again on data compliance during a weekly staff meeting, and will also counsel the involved staff member on the error to ensure there is no similar future error. xiv. Contact Person (s) Responsible for Corrective Action: Cassie Roach, Safe Parking Program Director, croach@sbnbcc.org Joel Goforth, Homeless Services Director, jgoforth@sbnbcc.org xv. Anticipated Completion Date: The anticipated completion date is April 30, 2025.

View Audit 350179

Finding 539638 (2024-003)

Significant Deficiency 2024

Nbcc

CA

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

vii. Management Response and Corrective Action Plan: The travel in question involved staff travel to the annual National Alliance to End Homelessness (NAEH) conference. As evidenced by correspondence with HUD AAQ, it has long been established that attending an NAEH conference is an eligible use of ...

vii. Management Response and Corrective Action Plan: The travel in question involved staff travel to the annual National Alliance to End Homelessness (NAEH) conference. As evidenced by correspondence with HUD AAQ, it has long been established that attending an NAEH conference is an eligible use of CoC and ESG grant funds. We perceived the historical general approval to be in alignment with the contract requirement of obtaining written approval for the reimbursement of costs incurred for travel outside the county. All costs submitted for reimbursement were eligible and reasonable expenses. We now understand this historical approval by HUD was not transferrable to this grant and therefore, moving forward, we will secure email approval of travel eligibility for specific grant reimbursement prior to travel. To that end, we have already been in contact with Housing and Community Development (HCD) fiscal staff at Santa Barbara County about a reliable method to secure said approvals in advance moving forward. If travel is not approved for a specific grant, or not obtained prior to travel, other unrestricted income will be utilized for that portion of the travel expenses. viii. Contact Person (s) Responsible for Corrective Action: Kristine Schwarz, Executive Director, kschwarz@sbnbcc.org Victoria Garfield, Grants Administrator, vgarfield@sbnbcc.org ix. Anticipated Completion Date: Staff anticipate attending the annual NAEH conference this year, therefore we will request approval once registration is confirmed and expect to receive approval or rejection from County CD staff by no later than the date of travel, or approximately July 15, 2025.

View Audit 350179 Questioned Costs: $1

Finding 539631 (2024-001)

Material Weakness 2024

Argus Manor Association

WA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

S3800-010: Finding Reference Number 2024-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification and review of tenant files by an indep...

S3800-010: Finding Reference Number 2024-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification and review of tenant files by an independent contractor prior to finalization of new tenant move-in. However, during our testing, we noted five (5) move-in files out of five (5) move-in files tested where tenants were approved for move-in prior to review and approval by the independent contractor, circumventing the control. S3800-080: Auditor Recommendation: We recommend that the client immediately implement corrective actions to ensure compliance with internal control procedures. Specifically: 1. The compliance specialist should be required to wait for proper approval of tenant eligibility files before processing them. 2. Review and reinforce the approval process through additional training for staff to ensure they understand the critical importance of obtaining necessary approvals before proceeding. 3. Implement stronger oversight and monitoring mechanisms to ensure that files are not processed before approval. S3800-045: Actions Taken or to be Taken: Management has reviewed the policies and procedures with the property manager, who also serves as the compliance specialist. The property manager was instructed that no tenants are to be granted occupancy until the file has been approved by the independent contractor conducting the compliance review.

View Audit 350177

Finding 539621 (2024-001)

Significant Deficiency 2024

City of Simi Valley

CA

Reporting Internal Control / Segregation of Duties § 200.328 § 200.502 § 200.510

The City internally identify improvement opportunities in managing grants. As a part of the City’s grant oversight improvement efforts, the City began implementing various processes and internal controls surrounding grant monitoring, which improves the SEFA drafting process and mitigates risks of f...

The City internally identify improvement opportunities in managing grants. As a part of the City’s grant oversight improvement efforts, the City began implementing various processes and internal controls surrounding grant monitoring, which improves the SEFA drafting process and mitigates risks of future inaccuracies. These efforts began in early 2024 and include the following: • Creation of a grant policy that provides City staff with guidance, information, and expectations surrounding grants. • Creation of a master grants database that lists the general ledger fund, applicable project ledger references, status, grant type, start/end dates, granting agency, pass-through agency, grant name, assistance listing numbers, grant amounts, and the grant manager for each grant. This database is now used to verify the completeness and accuracy of the SEFA (beginning FY24). • Formal quarterly monitoring. Each quarter, the City will formally review the grants database with department contacts and grant managers to verify the completeness and accuracy of the database. The City is formalizing this process and plans to include department signoffs evidencing the review process. If any items are missing, the missing component will be identified and added to the database on a timely basis. The City will also utilize this quarterly process to review the grants policy to ensure grant managers are aware of the requirements related to their grants. • The City is in the process of formalizing the SEFA drafting process utilized during the FY24 SEFA preparation, which includes additional mitigating procedures such as reviewing all next FY federal receipts to ensure none of them relate to the SEFA year federal expenditures. Personnel Responsible for Implementation: Marvin Lopez Position of Responsible Personnel: Deputy Administrative Services Director (Fiscal Services) Expected Date of Implementation: June 30, 2025

View Audit 350154

Finding 539606 (2024-001)

Significant Deficiency 2024

Horatio School District

AR

Questioned Costs Procurement, Suspension & Debarment Cash Management

Horatio School District will contact the Federal Communications Commission for guidance regarding this matter and reimbursement. Anticipated completion date: April 15, 2025.

View Audit 350148 Questioned Costs: $1

Finding 539593 (2024-001)

Significant Deficiency 2024

Occidental College

CA

Student Financial Aid Special Tests & Provisions Reporting

Occidental College Corrective Action Plan Finding 2024-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control Over Compliance Explanation of Deficiency: Occidental sent a degree file to the National Student Clearinghouse (NSC) on June 12, 2024. It was...

Occidental College Corrective Action Plan Finding 2024-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control Over Compliance Explanation of Deficiency: Occidental sent a degree file to the National Student Clearinghouse (NSC) on June 12, 2024. It was a sent a week after an enrollment file. The enrollment file had errors which required resolution before the NSC could process the degree file. The enrollment file errors were remedied on June 25, 2024. The degree file also had errors posted on June 26, 2024, and corrected by Occidental on July 29, 2024. Correction Action Plan: The staff member currently responsible for resolving National Student Clearinghouse (NSC) file errors has now been trained in the institutional responsibility to send NSC files on time and to resolve any resulting errors immediately. In additional, the College will soon be hiring an administrative position (currently open) in the Registrar’s Office who will act as Occidental’s main liaison with the NSC. Plans for the new liaison training include both NSC processing as well as the relationship between NSC submissions and the institutional responsibility to report accurate enrollment to the National Student Loan Data System (NSLDS) as required. Training will be conducted by the Registrar with the assistance of the Director of Financial Aid for emphasis on institutional responsibilities as outlined in 34 CFR 685.3096(b). Contact Person Responsible for Corrective Action: James Herr, Occidental College Registrar Anticipated Completion Date: December 12, 2024 (end of Fall semester but before next degree file is sent to NSC)

View Audit 350130

Finding 539584 (2024-004)

Material Weakness 2024

West Mifflin Area School District

PA

Questioned Costs Special Tests & Provisions Matching / Level of Effort / Earmarking

FINDING 2024-004: US Department of Education and PA Department of Education - COVID-19 Education Stabilization Fund (ESF) - ALN #84.425 - Special Tests and Provisions - Wage Rate Requirements Criteria: In accordance with Uniform Guidance requirements found in Part 3 Section N, "Special Tests and Pro...

FINDING 2024-004: US Department of Education and PA Department of Education - COVID-19 Education Stabilization Fund (ESF) - ALN #84.425 - Special Tests and Provisions - Wage Rate Requirements Criteria: In accordance with Uniform Guidance requirements found in Part 3 Section N, "Special Tests and Provisions" of the Compliance Supplement, all laborers and mechanics employed by contractors or subcontractors to work on construction contracts in excess of $2,000 financed by federal assistance funds must be paid wages not less than the prevailing wages rates established by the Department of Labor (DOL). Nonfederal entities shall include in their construction contracts subject to the Wage Rate Requirements a provision that the contractor or subcontractor comply with those requirements and DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance. Condition: The School District did not have adequate internal control procedures in place to ensure that all laborers and mechanics employed by contractors or subcontractors to work on construction contracts in excess of $2,000 financed by federal assistance funds were paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor. As a result, the School District did not properly notify 1 of the 3 contractors tested of the requirements to comply with the wage rate requirements via the including of a prevailing wage rate clause in the contract between the contractor and the School District, and therefore, the use prevailing wage rates were not determined. Cause: The School District did not have formal procedures in place to ensure that prevailing wage rate requirements were met on all construction projects over $2,000. Effect: The School District was not in compliance with the Special Tests and Provisions - Wage Rate Requirements of the Uniform Guidance. Repeat Finding: No Questioned Costs: Unknown Recommendation: We recommend that the School District revise its purchasing policy to formally reflect the requirements of Special Tests and Provisions - Wage Rate Requirements. Additionally, we recommend that the School District establish procedures to ensure that prevailing wage rate requirements are met for federally funded construction projects over $2,000. Views of Responsible Officials and Planned Corrective Action: The School District agrees with the recommendation. The Business Office will require that projects over $2,000 involving federal must use prevailing wage rates.

View Audit 350127 Questioned Costs: $1

Finding 539578 (2024-002)

Significant Deficiency 2024

Housing Authority of the City of Annapolis

MD

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Corrective Action Plan: The Authority concurs with the finding. The following corrective actions are being implemented:  Reinstating and enhancing the inspection tracking log to monitor timely completion of all required inspections;  Utilizing property management software to schedule and track ins...

Corrective Action Plan: The Authority concurs with the finding. The following corrective actions are being implemented:  Reinstating and enhancing the inspection tracking log to monitor timely completion of all required inspections;  Utilizing property management software to schedule and track inspections;  Assigning oversight responsibility for inspections to the Property Manager and Safety Inspection Supervisor;  Conducting quarterly management reviews of inspection compliance;  Hired additional inspection sta􀀳, including Maintenance Operations Supervisor to complete any backlog and ensure ongoing compliance.  Requested funding from City, State, and County to assist in inspections compliance to address federal funding and revenue shortages due to rental income delinquency. Anticipated Completion Date: June 30, 2025 Responsible Party: Senior Manager of Housing Operations/Maintenance Manager

View Audit 350123

Finding 539577 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Annapolis

MD

Eligibility HUD Housing Programs Significant Deficiency

Corrective Action Plan: The Authority acknowledges the finding. Corrective actions to address the deficiencies are underway and include:  Updating internal policies and procedures related to tenant file documentation and income verification requirements;  Providing targeted sta􀀳 training on proper...

Corrective Action Plan: The Authority acknowledges the finding. Corrective actions to address the deficiencies are underway and include:  Updating internal policies and procedures related to tenant file documentation and income verification requirements;  Providing targeted sta􀀳 training on proper file documentation and third-party income verification procedures;  Implementing a mandatory checklist to ensure all required documentation is obtained and verified before finalizing recertifications;  Establishing a quality control process where supervisory sta􀀳 conduct periodic file reviews to ensure compliance;  Maintaining an audit trail of verification documentation to ensure proper retention.  Hired third-party service provider, Quadel to assist with tenant file documentation compliance, annual and interim recertifications and rent calculations.  Hiring Senior Housing Manager to assist with monitoring verification documentation, income calculation, citizenship and/or legal residency documentation, and signed release documentation compliance. Anticipated Completion Date: June 30, 2025 Responsible Party: Senior Manager of Housing Operations and PH Property Managers

View Audit 350123

Finding 539575 (2024-001)

Significant Deficiency 2024

Primary Connection Health Care, Inc.

WI

Eligibility Internal Control / Segregation of Duties Special Tests & Provisions

We have determined that the sliding fee set up in our EHR will miscalculate a patient’s sliding fee discount when a combination of particular conditions are met. A representative of the EHR company has confirmed that the system “does not behave as it should” when these circumstances occur. While it...

We have determined that the sliding fee set up in our EHR will miscalculate a patient’s sliding fee discount when a combination of particular conditions are met. A representative of the EHR company has confirmed that the system “does not behave as it should” when these circumstances occur. While it is rare that a slide patient would meet all of these conditions, it does happen from time to time. Because of this, we have begun verifying the discounts applied to every slide patient’s account to ensure accuracy. Additionally, we are restructuring the sliding fee discount program and will rebuild it within the EHR to remove the possibility of one of the conditions occurring, which should prevent the system from ever miscalculating the discount to be applied. Person(s) Responsible: Kim Wieloch, Finance Director Timing for Implementation: Verifying all SFS discounts: Currently in process and ongoing; Rebuilding SFS calculation structure in EHR: By 7/1/2025

View Audit 350122

Finding 539564 (2024-001)

Significant Deficiency 2024

Jewish Community Center of Staten Island, Inc.

NY

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

2024-001 Special Tests and Provisions Name of Contact Person: Adam Miller, Chief Financial Officer Corrective Action: The JCC was unable to meet certain performance-based provisions of the contract, such as number of participants and break out of those participants by age category. The JCC acknowled...

2024-001 Special Tests and Provisions Name of Contact Person: Adam Miller, Chief Financial Officer Corrective Action: The JCC was unable to meet certain performance-based provisions of the contract, such as number of participants and break out of those participants by age category. The JCC acknowledges and agrees with the finding, and is in the process of developing procedures to ensure compliance with the grant/contract provisions and will start implementing this recommendation during the year ended June 30, 2025. The procedures: • The JCC will designate the responsibility of contract compliance to a specific individual at the JCC. • The JCC will ensure strict compliance with the IS49 Beacon program’s grant/contract provisions.

View Audit 350115

Finding 539560 (2024-005)

Significant Deficiency 2024

St John Public School District No. 3

ND

Reporting Internal Control / Segregation of Duties

Contact Person Mary Vandal, Business Manager Planned Corrective Action This finding was noted by the auditors on the Impact Aid application submitted in January 2023. Both applications submitted in January of 2024 and 2025 had the proper support showing student enrollment information with review or ...

Contact Person Mary Vandal, Business Manager Planned Corrective Action This finding was noted by the auditors on the Impact Aid application submitted in January 2023. Both applications submitted in January of 2024 and 2025 had the proper support showing student enrollment information with review or approval by tribal authority prior to submitting the application. Applications made in the future will continue to have the required documentation to support the application. Planned Completion Date June 30, 2025

View Audit 350113

Finding 539554 (2024-001)

Significant Deficiency 2024

La Asociacion Nacional Pro Personas Mayores (the National Association for Hispanic Elderly)

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The Association’s management acknowledges the finding and has been working with DOL personnel on completing the required indirect cost rate proposals. Management will also engage a consultant to assist with the completion of the indirect cost rate proposals as soon as feasible.

View Audit 350103

Finding 539551 (2024-005)

Significant Deficiency 2024

City of Alexandria

VA

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.213 § 200.303 § 200.318

DCHS has reviewed its procedures and will ensure that awards are reported timely and accurately to FSRS and that documenation of compliance will be available for review.

View Audit 350101

Finding 539550 (2024-004)

Material Weakness 2024

City of Alexandria

VA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DCHS has reviewed its procedures and will ensure that suspension and debarement status is documented prior to contracting with a vendor.

View Audit 350101

Corrective Action Plans

Filters