Corrective Action Plans

Finding 524220 (2024-001)

Significant Deficiency 2024

CT

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will ass...

SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will assign random audits on a Monthly basis of patients that are assigned a sliding fee. 2) Director of Program Management as well as Program Managers will monitor Phreesia dashboard to identify self-pay patients on the schedule and work to ensure that accounts are updated accordingly. a. For any accounts that need to be updated, they will inform the PSA who checked in the patient to make the updates as necessary and provide additional training if needed. b. Provide trainings to PSAs to ensure that they are offering the Sliding Fee Discount to all patients that may need to apply, and appropriately applying those slides. 3) If a Pt has had a visit and left prior to getting sliding fee information, PSAs are to call the patient to let them know that they may have to apply for a sliding fee (or receive insurance information over the phone). 4) Practice Managers will identify Self-pay accounts via Phreesia each morning that may need attention and send a list of accounts to the PSAs at the beginning of each day. PSA will then contact the patients to remind them to bring in proof of income to apply for the sliding fee if eligilble.

View Audit 343418

Finding 524208 (2024-005)

Significant Deficiency 2024

Montcalm Community College

MI

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

2024-005 – Pell Grant Calculation. Auditor Description of Condition and Effect. One student out of the twenty five Pell grants tested was found to be under awarded based on the enrollment status and cost of attendance. As a result of this condition, the College was exposed to an increased risk that ...

2024-005 – Pell Grant Calculation. Auditor Description of Condition and Effect. One student out of the twenty five Pell grants tested was found to be under awarded based on the enrollment status and cost of attendance. As a result of this condition, the College was exposed to an increased risk that incorrect information would be used to determine students' Pell Grant award amounts. Auditor Recommendation. We recommend the College implement procedures to ensure the COA and EFC used to calculate each student's Pell Grant is updated for each academic year and reviewed by an independent official. Corrective Action. This is corrected on setup and noted to correct the COA. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. March 2025 - next set up, it was corrected for 24/25 academic year in May 2024.

View Audit 343397

Finding 524203 (2024-004)

Significant Deficiency 2024

Montcalm Community College

MI

Questioned Costs Student Financial Aid Reporting

2024-004 – Fiscal Operations Report and Application to Participate (FISAP) Reporting. Auditor Description of Condition and Effect. It was noted during our testing of the FISAP that the College did not have support for one of the eight key line items identified in the compliance supplement as critica...

2024-004 – Fiscal Operations Report and Application to Participate (FISAP) Reporting. Auditor Description of Condition and Effect. It was noted during our testing of the FISAP that the College did not have support for one of the eight key line items identified in the compliance supplement as critical information. The College is not in compliance with the Department of Education requirements that state the FISAP must be accurately reporting information. Auditor Recommendation. We recommend the College review their policies and procedures surrounding FISAP reporting. Corrective Action. Adjust notes on the procedure (or guidelines), laying out the complete steps of FISAP to ensure the data is accurate. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. February 2025 - the next FISAP.

View Audit 343397

Finding 524193 (2024-002)

Significant Deficiency 2024

Montcalm Community College

MI

Questioned Costs Special Tests & Provisions Student Financial Aid

2024-002 – Return of Title IV (R2T4) Calculation. Auditor Description of Condition and Effect. During our testing of six students with Return of Title IV amounts, we noted that the College did not exclude the correct amount of days for scheduled breaks of five days or more in both the fall 2023 and ...

2024-002 – Return of Title IV (R2T4) Calculation. Auditor Description of Condition and Effect. During our testing of six students with Return of Title IV amounts, we noted that the College did not exclude the correct amount of days for scheduled breaks of five days or more in both the fall 2023 and spring 2024 terms, resulting in the incorrect Return of Title IV calculation for all students tested. As a result of this condition, the students' return of funds calculation was not done correctly and the return of funds back to the federal government was for the incorrect amount. Auditor Recommendation. We recommend the College review the Return of Title IV requirements and implement procedures to ensure the Return of Title IV calculations are using the correct amount of term days and are completed accurately. Corrective Action. This has been noted in setup notes, so the number of days are correct going forward. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. November 2024.

View Audit 343397

Finding 524186 (2024-001)

Material Weakness 2024

Umatilla Morrow Head Start, Inc.

OR

Internal Control / Segregation of Duties Questioned Costs Material Weakness § 200.302

Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. recently added capacity and experience to the finance department by hiring two new staff members, a Payroll Specialist and an AP and Procurement Specialist. In addition, best practices and reconciliati...

Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. recently added capacity and experience to the finance department by hiring two new staff members, a Payroll Specialist and an AP and Procurement Specialist. In addition, best practices and reconciliation timelines and guidance are being captured in financial policies and procedures being updated at this time. UMHS has also implemented new software tools that will assist in automating the department, providing additional time for staff members to implement a monthly review that includes reconciliations and tracking. This "internal auditing" process is relatively new to the department and will add a layer of accountability and accuracy in the recording and processing of the organization's financial activity. In addition, UMHS initiated recruitment for a permanent Director of Finance in summer 2024 and the search to hire for this position is open and ongoing. To supplement and support the current staff, UMHS will continue to provide additional training and guidance to the finance team to stay ahead of changes to federal and state guidelines, and to build on the knowledge and experience of the team. Adding a permanent Director of Finance will be essential as that staff member will be a member of the Senior Leadership Team and working in supporting and staffing the monthly Finance Committee meetings and supporting the UMHS Board of Directors' Treasurer. UMHS Senior Leadership Team will review and approve year-end financial schedules being provided to the auditors, as well as provide additional oversight and approval of year-end entries and closing processes. Timing for Implementation: Immediate and Ongoing Person(s) Responsible: Executive Director, Director of Finance, or Designee

View Audit 343360

Finding 524171 (2024-001)

Material Weakness 2024

Louisiana Delta Service Corps

LA

Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303

Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. We will ensure the areas recommended above are added to our current policy to the extent it is economically feasible.

View Audit 343346

Finding 524163 (2024-005)

Significant Deficiency 2024

Madison Commuity Unit School District #12

IL

Reporting Internal Control / Segregation of Duties Questioned Costs

Condition: We noted that six of the quarterly expenditure reports were not filed in a timely manner. There were expenses with dates on them that should have been reported in earlier quarter reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ens...

Condition: We noted that six of the quarterly expenditure reports were not filed in a timely manner. There were expenses with dates on them that should have been reported in earlier quarter reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Management Response: Management will take the necessary steps to file all quarterly reports on time in the future.

View Audit 343341

Finding 524162 (2024-007)

Significant Deficiency 2024

Madison Commuity Unit School District #12

IL

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and th...

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting.

View Audit 343341

Finding 524150 (2024-003)

Significant Deficiency 2024

City of Santa Fe

NM

Cash Management Reporting Significant Deficiency § 200.302 § 200.303

Auditor recommendation: We recommend that the City establish policies and procedures for requesting reimbursement of grant expenditures on a monthly basis, including reconciliation of the expenditures and reimbursements under each grant. Views of Responsible Oﬃcials and Planned Correc􀀁ve Ac􀀁on: The ...

Auditor recommendation: We recommend that the City establish policies and procedures for requesting reimbursement of grant expenditures on a monthly basis, including reconciliation of the expenditures and reimbursements under each grant. Views of Responsible Oﬃcials and Planned Correc􀀁ve Ac􀀁on: The City agrees with this ﬁnding. Vacancies in key posi􀀁ons including the Airport Manager and the Transit Director of Administra􀀁on meant that there was not suﬃcient exper􀀁se in the program areas to ensure that reimbursement requests were prepared and submi􀀂ed 􀀁mely. These key posi􀀁ons have now been ﬁlled. The City now has an Airport Manager with substan􀀁al experience managing municipal airports and overseeing federal funding for airports. The City also hired a Transit Director of Administra􀀁on with extensive federal and state grant management experience, and exper􀀁se in Transit programs. The Accoun􀀁ng Oﬃcer, Grants Manager and Accoun􀀁ng Financial Analyst posi􀀁ons in the Finance Department have been ﬁlled, and the Grants Division is now fully staﬀed. More robust staﬃng is allowing Finance to perform more oversight in addi􀀁on to working more closely with Transit and Airport program staﬀ. Filling these key posi􀀁ons and retaining qualiﬁed staﬀ is essen􀀁al to establishing a process for 􀀁mely requests for reimbursement, and reconcilia􀀁on of expenditures and reimbursement under each grant. The Transit Division is working with a contractor provided by the FTA on establishing policies and procedures to ensure compliance with federal grant requirements. This contractor is also providing training and technical assistance to the Transit program. The scope of this work includes ensuring requests for reimbursement of grant expenditures are submi􀀂ed 􀀁mely, and reconcilia􀀁ons of grant expenditures and reimbursements are completed 􀀁mely and accurately. The Airport Department is in the process of contrac􀀁ng with a vendor to assist with federal compliance and provide training for Airport staﬀ on relevant Uniform Guidance requirements. The vendor’s scope of work will include helping with developing and documen􀀁ng policies and standard opera􀀁ng procedures for requests for reimbursement, and reconcilia􀀁on of expenditures and reimbursements. Addi􀀁onally, the Airport Department plans to create a Grant Accountant posi􀀁on which will be responsible for reconciling grant expenditures monthly and processing reimbursement requests quarterly. In CY25 the City plans to provide Uniform Guidance training for staﬀ which will include internal controls related to cash management. Responsible Oﬃcial:Emily Oster, Finance Director, James Harris, Airport Manager, Airport Heavy Equipment Mechanic, Gabrielle Chavez, Transit Director of Administration, Matthew Bonifer, Accounting Officer, Erika Lujan, Grants Manager Timeline and Es􀀁mated Comple􀀁on Date: June 30, 2025

View Audit 343340

Finding 524108 (2024-005)

Significant Deficiency 2024

Natrona County, Wyoming

WY

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring

Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously...

Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. To further stabilize and formalize these improvements, a Certified Public Accountant will be added as a consulting CFO. This role supports the ongoing development of fiscal operations. Additionally, it is recognized that the payroll vendor, ADP, was initially slow to address issues with uploaded data when notified by CAPNC, responded officially after CAPNC alerted repeatedly that it had now elevated to an audit issue. This issue has since been remedied. Staff have shown marked improvement over previous legacy staff in documentation, accountability, and monitoring. Payroll services in general are able to provide real-time features and accountability for time, resulting in more accurate, reliable, and allocable time recording. Payroll records are reviewed, and time studies are performed for all staff to ensure the allocation methodology is appropriate, consistent, and aligned with staff performance. Wipfli Consulting is providing technical assistance over an additional contract period to update policies and procedures for the fiscal area, in accordance with Uniform Guidance, and allow for advance reporting, as well as provide CPA support. The curriculum includes comprehensive training for all administrative leadership staff, covering fiscal oversight, grants management, and compliance. Allocations are regularly reviewed by the leadership team to ensure appropriate methodology and consistency with grant expectations and regulations. Board members have access to the accounting software through a Board portal for further oversight, enhancing transparency and accountability. Review of finance in conducted monthly by Board of Director’s Finance Committee.

View Audit 343312

Finding 524106 (2024-004)

Material Weakness 2024

Natrona County, Wyoming

WY

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.400

Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously...

Over the past year, CAPNC has continued to make significant improvements to its fiscal practices, particularly in navigating the software conversion from an archaic, unsupported system to Sage Intacct. This new software has modernized and deployed the levels of internal controls that were previously missing due to inadequate fiscal personnel oversight and technical capability. Current staff have been trained under Sage Intacct and Wipfli consultants to properly track accounts payable (A/P), accounts receivable (A/R), payroll, and grant management, ensuring data integrity and compliance. Resulting journal entries are in place to bring system in alignment and current as of July 2024, alleviating any further discrepancies related to past staff and old software. The old system will be archived as required under retention. To further stabilize and formalize these improvements, a Certified Public Accountant will be added as a consulting CFO. This role supports the ongoing development of fiscal operations. Additionally, it is recognized that the payroll vendor, ADP, was initially slow to address issues with uploaded data when notified by CAPNC, responded officially after CAPNC alerted repeatedly that it had now elevated to an audit issue. This issue has since been remedied. Staff have shown marked improvement over previous legacy staff in documentation, accountability, and monitoring. Payroll services in general are able to provide real-time features and accountability for time, resulting in more accurate, reliable, and allocable time recording. Payroll records are reviewed, and time studies are performed for all staff to ensure the allocation methodology is appropriate, consistent, and aligned with staff performance. Wipfli Consulting is providing technical assistance over an additional contract period to update policies and procedures for the fiscal area, in accordance with Uniform Guidance, and allow for advance reporting, as well as provide CPA support. The curriculum includes comprehensive training for all administrative leadership staff, covering fiscal oversight, grants management, and compliance. Allocations are regularly reviewed by the leadership team to ensure appropriate methodology and consistency with grant expectations and regulations. Board members have access to the accounting software through a Board portal for further oversight, enhancing transparency and accountability. Review of finance in conducted monthly by Board of Director’s Finance Committee.

View Audit 343312 Questioned Costs: $1

Finding 524086 (2024-002)

Significant Deficiency 2024

City of Newton

NC

Significant Deficiency Internal Control / Segregation of Duties

Name of Contact Person: Kimberley Robinson, Finance Director Corrective Action/Management’s Response: In January 2024 the City of Newton implemented the following corrective action plan in response to finding 2023-001; however, during the audit process for FY24 timesheets were reviewed that were pri...

Name of Contact Person: Kimberley Robinson, Finance Director Corrective Action/Management’s Response: In January 2024 the City of Newton implemented the following corrective action plan in response to finding 2023-001; however, during the audit process for FY24 timesheets were reviewed that were prior to this implementation date. The City of Newton makes every effort to ensure that timesheets are submitted, signed, reviewed, and entered in the payroll system accurately and efficiently. Once timesheets are approved by supervisors they are sent to HR for processing. If at any time during this process the HR staff member entering the information is aware of missing approval or other information on the timesheet, they will verify the data with the supervisor and sign off on the timesheet in an effort to not delay the weekly timesheet processing. This will be notated on the timesheet for documentation purposes. Proposed Completion Date: Immediate and ongoing

View Audit 343240

Finding 524043 (2024-003)

Material Weakness 2024

Wyalusing Area School District

PA

Internal Control / Segregation of Duties

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Year ended June 30, 2024 Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the pronouncement, the District should continue to review and accept both pro...

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Year ended June 30, 2024 Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. School District’s Response: Stephanie Heller, Business Manager, has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information for the year ending June 30, 2025 and in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the District considers such assistance provided by the auditors to be the most cost effective in preparing such information.

View Audit 343231

Finding 524041 (2024-003)

Material Weakness 2024

Metro Technology Center

OK

Questioned Costs Subrecipient Monitoring Material Weakness

Finding Summary: U.S. Department of Treasury COVID-19- Coronavirus State and Local Fiscal Recovery Funds (SLFRF) (FFAL #20.027) Reporting Material Weakness in Internal Control over Compliance Responsible Individuals: Karla Graham, Director of Grants, Services & Projects Corrective Action Plan: The p...

Finding Summary: U.S. Department of Treasury COVID-19- Coronavirus State and Local Fiscal Recovery Funds (SLFRF) (FFAL #20.027) Reporting Material Weakness in Internal Control over Compliance Responsible Individuals: Karla Graham, Director of Grants, Services & Projects Corrective Action Plan: The process has been adjusted to ensure quarterly project and expenditure reports are reviewed independently by two different people prior to submission. Anticipated Completion Date: July 1, 2025

View Audit 343223

Finding 524036 (2024-005)

Significant Deficiency 2024

Metro Technology Center

OK

Questioned Costs Student Financial Aid Eligibility

Finding Summary: U.S. Department of Education Student Financial Aid Cluster (FAL # 84.268, 84.063) Eligibility Significant Deficiency in Internal Control over Compliance Responsible Individuals: Alicia Smith, Director of Financial Aid Corrective Action Plan: The process has been adjusted to ensure m...

Finding Summary: U.S. Department of Education Student Financial Aid Cluster (FAL # 84.268, 84.063) Eligibility Significant Deficiency in Internal Control over Compliance Responsible Individuals: Alicia Smith, Director of Financial Aid Corrective Action Plan: The process has been adjusted to ensure manual calculations are done independently by two different people. Anticipated Completion Date: July 1, 2025

View Audit 343223

Finding 524031 (2024-004)

Significant Deficiency 2024

Metro Technology Center

OK

Questioned Costs Student Financial Aid Significant Deficiency

Finding Summary: U.S. Department of Education Student Financial Aid Cluster (FFAL #84.268 and #84.063) Special Test: Return of Funds Significant Deficiency in Internal Control over Compliance Responsible Individuals: Alicia Smith, Director of Financial Aid Corrective Action Plan: The process has bee...

Finding Summary: U.S. Department of Education Student Financial Aid Cluster (FFAL #84.268 and #84.063) Special Test: Return of Funds Significant Deficiency in Internal Control over Compliance Responsible Individuals: Alicia Smith, Director of Financial Aid Corrective Action Plan: The process has been adjusted to ensure manual calculations are done independently by two different people. Anticipated Completion Date: July 1, 2025

View Audit 343223

Finding 524027 (2024-001)

Significant Deficiency 2024

Sheridan School District

OR

Questioned Costs Reporting School Nutrition Programs

The District took immediate steps to remedy the issue, new reviews are required before and after submission. The Business Manager and Food Services Director have implemented the changes.

View Audit 343221

Finding 524016 (2024-004)

Significant Deficiency 2024

Northwestern Health Sciences University

MN

Questioned Costs Student Financial Aid Significant Deficiency

Return of Title IV Funds Recommendation: We recommend the University review the R2T4 calculations and the term dates used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university will manually review student...

Return of Title IV Funds Recommendation: We recommend the University review the R2T4 calculations and the term dates used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university will manually review student registration begin and end dates for all students where withdrawal records indicate a R2T4 calculation may be required. This review will ensure appropriate dates are used for determining the need for a R2T4 calculation, and for student records requiring a R2T4 calculation, that the calculation is completed using the correct number of days. Name of the contact person responsible for corrective action: Scott Roelke, Director of Financial Aid Planned completion date for corrective action plan: In place as of February 14, 2025.

View Audit 343204 Questioned Costs: $1

Finding 524015 (2024-003)

Significant Deficiency 2024

Northwestern Health Sciences University

MN

Questioned Costs Student Financial Aid Significant Deficiency

Perkins Recommendation: We recommend that the University implement a procedure to ensure that all necessary MPNs are retained in accordance with the federal regulation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findin...

Perkins Recommendation: We recommend that the University implement a procedure to ensure that all necessary MPNs are retained in accordance with the federal regulation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the audit finding where some MPNs are missing. We are unable to correct the past but moving forward, the new ones are being retained. Name of the contact person responsible for corrective action: Jane Garner, CFO Planned completion date for corrective action plan: Already in place

View Audit 343204

Finding 524010 (2024-002)

Significant Deficiency 2024

Northwestern Health Sciences University

MN

Questioned Costs Student Financial Aid Reporting

National Student Loan Data System (NSLDS) Recommendation: We recommend reviewing the components of the enrollment roster file to ensure the correct effective date is reported correctly for both the “Campus Level” and “Program Level”. Explanation of disagreement with audit finding: There is no disagr...

National Student Loan Data System (NSLDS) Recommendation: We recommend reviewing the components of the enrollment roster file to ensure the correct effective date is reported correctly for both the “Campus Level” and “Program Level”. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Although the Colleague data is correct, the logic in Colleague used to send the files to the NSC is excluding records when the student is not registered for classes in the month an action such as graduation or withdrawal occurs. In that situation the NSC is inserting default dates onto the record based on the last date of their classes in the prior term. We are working with our IT team & Ellucian on an approach to update that logic. In the meantime, we will implement a reporting solution to allow manual correction of these issues. Name of the contact person responsible for corrective action: Kris Ragozzino, Registrar Planned completion date for corrective action plan: Already in place.

View Audit 343204

Finding 523978 (2024-007)

Significant Deficiency 2024

Granville County, North Carolina

NC

Questioned Costs Eligibility Internal Control / Segregation of Duties

For the Year Ended June 30, 2024 Corrective Action Plan Proposed completion date: Finding 2024-006 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Finding 2024-007 Inaccurate Information Entry Name of contact person: Refresher training will be ...

For the Year Ended June 30, 2024 Corrective Action Plan Proposed completion date: Finding 2024-006 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Finding 2024-007 Inaccurate Information Entry Name of contact person: Refresher training will be held by December 31, 2024 on effective documentation and record keeping. “Vehicle Status Documentation” template will be created and implemented by December 31, 2024. Error Trends Data log was implemented October 1, 2024. Adult Medicaid Lead Workers will monitor this by conducting a random selection of second party reviews each month. Adult Income Maintenance Supervisor II (pending vacancy), Delta Elliott, Income Maintenance Lead Worker III, and Michelle Ogle, Income Maintenance Lead Worker III Error discovered where vehicle status was not clearly documented in the case record caused by ineffective record keeping and incomplete documentation. Refresher training will be held by 12/31/2024 to review appropriate documentation and record keeping in NC FAST and will be conducted by Adult Medicaid leadership. Adult Medicaid Supervisor will create a “Vehicle Status Documentation” template that will be utilized by all Adult Medicaid caseworkers at every application and recertification. Completion and uploading of this template will be required in NC FAST. Adult Medicaid Lead Caseworkers will monitor the use of the template during monthly second party reviews of each caseworker. Adult Medicaid Supervisor created and utilized an Error Trends Data log effective 10/1/2024. The Error Trends Data log captures monthly errors to identify trends among staff. This log also provides Adult Medicaid leadership with data regarding errors that are repetitive to help leadership conduct monthly or quarterly refresher training as well as individualized training for staff who continue to have repetitive errors. Staff who fail to utilize the “Vehicle Status Documentation” template and continue to have repetitive errors will be placed on a corrective action plan. Policy refresher training will be held before 12/31/2024 that will cover the IV-D Referral process with specific advisory that the policy is currently suspended until further notice per DHB (Admin Letter 13-23). The Recertification Documentation template was updated on 11/20/2024 and went into effect immediately to be used by all Family and Children’s Medicaid caseworkers. The Error Trends Data log was implemented on October 1, 2024. Family and Children’s Medicaid leadership will monitor this by conducting a random selection of second party reviews each month. Section III - Federal Award Findings and Questioned Costs (continued) Kim Grissom, Income Maintenance Supervisor II; Taylor White, Income Maintenance Supervisor II; Lisa Kornegay, Income Maintenance Lead Worker III; and Sherry Stainback, Income Maintenance Lead Worker III 176Corrective Action Plan For the Year Ended June 30, 2024 Proposed completion date: Corrective actions for Finding 2024-005, 2024-006, and 2024-007 also apply to State Award findings. Errors discovered were income and household composition was calculated incorrectly due to inaccurate information being entered into NCFAST. Family and Children’s Medicaid leadership updated the Recertification Documentation Template on 11/20/2024 to ensure that accurate income, specifically UIB, and household composition is captured and documented appropriately. All Family and Children’s Medicaid caseworkers have been advised to utilize the updated Recertification Documentation Template effective immediately. The Family and Children Medicaid Supervisors created and utilizes an Error Trends Data log effective 10/1/2024. The Error Trends Data log captures monthly errors to identify trends among staff. This log also provides Family and Children Medicaid leadership with data regarding errors that are repetitive to help leadership conduct monthly or quarterly refresher training as well as individualized trainings for staff who continue to have repetitive errors. Staff who fail to utilize the updated Recertification Documentation template and continue to have repetitive errors will be placed on a corrective action plan. Refresher policy training will be held to ensure caseworkers understand policy surrounding income, specifically UIB, and household composition before 12/31/2024. The Recertification Documentation template was updated on 11/20/2024 and went into effect immediately to be used by all Family and Children’s Medicaid caseworkers. The Error Trends Data log was implemented on October 1, 2024. Family and Children’s Medicaid leadership will monitor this by conducting a random selection of second party reviews each month. Section IV - State Award Findings and Questioned Costs Section III - Federal Award Findings and Questioned Costs (continued) 177

View Audit 343198

Finding 523977 (2024-006)

Significant Deficiency 2024

Granville County, North Carolina

NC

Questioned Costs Eligibility Internal Control / Segregation of Duties

For the Year Ended June 30, 2024 Corrective Action Plan Proposed completion date: Finding 2024-006 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Finding 2024-007 Inaccurate Information Entry Name of contact person: Refresher training will be ...

For the Year Ended June 30, 2024 Corrective Action Plan Proposed completion date: Finding 2024-006 Inadequate Request for Information Name of contact person: Corrective Action: Proposed completion date: Finding 2024-007 Inaccurate Information Entry Name of contact person: Refresher training will be held by December 31, 2024 on effective documentation and record keeping. “Vehicle Status Documentation” template will be created and implemented by December 31, 2024. Error Trends Data log was implemented October 1, 2024. Adult Medicaid Lead Workers will monitor this by conducting a random selection of second party reviews each month. Adult Income Maintenance Supervisor II (pending vacancy), Delta Elliott, Income Maintenance Lead Worker III, and Michelle Ogle, Income Maintenance Lead Worker III Error discovered where vehicle status was not clearly documented in the case record caused by ineffective record keeping and incomplete documentation. Refresher training will be held by 12/31/2024 to review appropriate documentation and record keeping in NC FAST and will be conducted by Adult Medicaid leadership. Adult Medicaid Supervisor will create a “Vehicle Status Documentation” template that will be utilized by all Adult Medicaid caseworkers at every application and recertification. Completion and uploading of this template will be required in NC FAST. Adult Medicaid Lead Caseworkers will monitor the use of the template during monthly second party reviews of each caseworker. Adult Medicaid Supervisor created and utilized an Error Trends Data log effective 10/1/2024. The Error Trends Data log captures monthly errors to identify trends among staff. This log also provides Adult Medicaid leadership with data regarding errors that are repetitive to help leadership conduct monthly or quarterly refresher training as well as individualized training for staff who continue to have repetitive errors. Staff who fail to utilize the “Vehicle Status Documentation” template and continue to have repetitive errors will be placed on a corrective action plan. Policy refresher training will be held before 12/31/2024 that will cover the IV-D Referral process with specific advisory that the policy is currently suspended until further notice per DHB (Admin Letter 13-23). The Recertification Documentation template was updated on 11/20/2024 and went into effect immediately to be used by all Family and Children’s Medicaid caseworkers. The Error Trends Data log was implemented on October 1, 2024. Family and Children’s Medicaid leadership will monitor this by conducting a random selection of second party reviews each month. Section III - Federal Award Findings and Questioned Costs (continued) Kim Grissom, Income Maintenance Supervisor II; Taylor White, Income Maintenance Supervisor II; Lisa Kornegay, Income Maintenance Lead Worker III; and Sherry Stainback, Income Maintenance Lead Worker III 176

View Audit 343198

Finding 523680 (2024-001)

Significant Deficiency 2024

MacCormac College Dba Generations College

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-001 Student Financial Aid Cluster, Assistance Listing # 84.007, 84.033, 84.063, 84.268 Condition: The College could not timely retrieve all student records and show documentation of reviews and approvals related to student records. Corrective Action Plan: ...

Finding 2024-001 Student Financial Aid Cluster, Assistance Listing # 84.007, 84.033, 84.063, 84.268 Condition: The College could not timely retrieve all student records and show documentation of reviews and approvals related to student records. Corrective Action Plan: Objective: To ensure the timely retrieval of all student records and the proper documentation of reviews and approvals to meet regulatory requirements and to improve accountability in the Student Financial Aid Cluster. Corrective Actions: To address the conditions and ensure compliance with regulations, the following corrective actions will be taken: A. Improvement of Student Record Retrieval Process: • Upgrade and/or streamline systems used for storing and retrieving student records. • Conduct an audit of existing data storage systems to identify inefficiencies, technical glitches, or areas for improvement. • Implement an automated system for flagging and retrieving missing or incomplete records in real-time. B. Enhanced Documentation of Reviews and Approvals: • Revise and reinforce the process for documenting reviews and approvals for all student records, ensuring that every step is appropriately tracked and stored. • Implement a centralized digital approval system to reduce paperwork and ensure easier tracking of approvals. C. Staff Training and Awareness: • Provide comprehensive training for all staff involved in financial aid processing on the importance of timely record retrieval and proper documentation of reviews and approvals. • Implement periodic refresher courses for staff, with a focus on improving accuracy in the review and approval process. D. Enhanced Communication and Coordination: • Establish a cross-functional team responsible for monitoring the status of student records, identifying delays, and ensuring approvals are documented. • Create an internal tracking system for ensuring the timely completion of records reviews and approvals. Monitoring and Follow-Up: To ensure that the corrective actions are being implemented effectively, the College will engage in internal reporting (monthly), external audit (annually), and a third-party review (annually) Person(s) Responsible for Corrective Action Plan: Jamieta Hoskins, Director of Financial Aid Anticipated Completion Date for Corrective Action Plan: April 30, 2025

View Audit 343124

Finding 523661 (2024-001)

Significant Deficiency 2024

YWCA Delaware Inc.

DE

Internal Control / Segregation of Duties Reporting

YWCA Delaware, Inc. will implement procedures and policies to enable it to identify the required reporting requirements for federal awards throughout the year and at year end and ensure all reports are filed timely and accurately.

View Audit 343074

Finding 523659 (2024-002)

Significant Deficiency 2024

Treasure Valley Community College

OR

Student Financial Aid Special Tests & Provisions Reporting

To address the discrepancies, TVCC has taken the following actions: 1. Properly updated the enrollment status of each of the three (3) identified students in the National Student Clearinghouse (NSC) via NSC’s “Student Lookup” tool. 2. Identified and implemented a mechanism to correct the enrollment...

To address the discrepancies, TVCC has taken the following actions: 1. Properly updated the enrollment status of each of the three (3) identified students in the National Student Clearinghouse (NSC) via NSC’s “Student Lookup” tool. 2. Identified and implemented a mechanism to correct the enrollment status issues caused by CPCC issuance. 3. Assigned a dedicated NSC staff member to process enrollment report submissions and resolve errors. 4. The Registrar’s Office and Financial Aid Office , in collaboration with the Enterprise Systems Support Analyst, are implementing an internal audit tool to better screen enrollment and graduate reports before submission to NSC.

View Audit 343072

Corrective Action Plans

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