Corrective Action Plans

Finding 520909 (2024-009)

Significant Deficiency 2024

WV

Internal Control / Segregation of Duties Questioned Costs Special Tests & Provisions

FINDING 2024-009 Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: Wheeling University worked with ECSI regarding Perkins information. With the Perkins program ending, we realized that we needed to move in the direction of closing out Perkins ...

FINDING 2024-009 Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: Wheeling University worked with ECSI regarding Perkins information. With the Perkins program ending, we realized that we needed to move in the direction of closing out Perkins files/information. The University is currently working with ECSI so that we are able to submit Perkins information/files to the Department of Education. We are gathering information (promissory notes, bankruptcy details, payment information, etc.) to assist ECSI with the process. Anticipated Completion Date: June 2025

View Audit 340797

Finding 520907 (2024-007)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Questioned Costs Special Tests & Provisions

Name of Responsible Individual: Lori Kestner, Human Resources Generalist Corrective Action: The payroll Process for Federal Work Study: Student punches in on a computer or cell phone to log in and out when working at the start of their shift and the end of their shift. Timecards can be approved ...

Name of Responsible Individual: Lori Kestner, Human Resources Generalist Corrective Action: The payroll Process for Federal Work Study: Student punches in on a computer or cell phone to log in and out when working at the start of their shift and the end of their shift. Timecards can be approved by their supervisor/manager daily, weekly, or by the pay period which is every two weeks. The pay period ends on a Friday with the payroll processing to begin on the following Monday. On that Monday, all timecards must be corrected/updated and approved before they can be processed. Timecards with errors cannot be processed. Each Monday the supervisor/manager must log into the student timecard and "approve" the card for the pay period that ended on the past Friday. When the supervisor/manager opens the card on Monday it defaults to the current pay period and not the previous pay period that needs to be approved. The supervisor/manager must select the "previous" pay period in order to approve the card to be processed. In the case of the student in question, the supervisor/manager did not select the correct pay period and therefore approved the future timecard. As the payroll manager, I would have emailed him, the manager, that the card to be processed had not been approved. Upon that, he went back and approved the pay period that was to be processed. The approval on the next pay period that he mistakenly approved should have been removed. It was not. The process for card approvals is to check on the Monday of payroll the cards that are still in need of updates/corrections and approvals. A report is run and shows what cards our still without approval and with errors. The payroll manager communicates to the manager and the student that there are errors on the card and/or it still needs to be approved. Payment for that card cannot be made until errors are corrected and the card is approved. It is the supervisor and manager’s responsibility to ensure timecards are corrected and updated for processing. This error can be resolved with the supervisor/manager accountable for the accuracy of the time cards. Before processing a report, can be run by the payroll manager of the date/time of approval. All supervisors and managers who are responsible for the approval of timecards will be reeducated on the process and sign off that they understand their role. Those who do not adhere to the process will have additional training. As new supervisors and managers are hired, the process will be part of their on-boarding. Anticipated Completion Date: January 2025

View Audit 340797

Finding 520906 (2024-010)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Questioned Costs Student Financial Aid

FINDING 2024-010 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges the FISAP report was filed with incorrect data and not amended in a timely manner. The University has developed a series of internal controls and procedures to ensure t...

FINDING 2024-010 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges the FISAP report was filed with incorrect data and not amended in a timely manner. The University has developed a series of internal controls and procedures to ensure that the data provided for the FISAP will be accurate going forward. All balance sheet accounts will be reconciled on a monthly basis and all revenue will be recorded on the ledger in the time period that it is earned. A monthly income statement and balance sheet will be generated to determine how much federal aid revenue has been reported throughout the year. The accounting software has a built-in process that will be run on a regular basis to make sure all entries are properly posted. This will ensure accurate reporting in the future. Anticipated Completion Date: June 2025

View Audit 340797

Finding 520905 (2024-006)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Questioned Costs Special Tests & Provisions

Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: The University acknowledges that we were not in compliance during fiscal year 2024 with the federal guidelines to refund the student credit balances in a timely manner for the students in questio...

Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: The University acknowledges that we were not in compliance during fiscal year 2024 with the federal guidelines to refund the student credit balances in a timely manner for the students in question. There was significant employee turnover at the University in the business office during fiscal year 2024 and training of new employees was ongoing at that time. This resulted in the delay in the student refunds within the sample selection that the auditors chose during fiscal year 2024. Since then the new and current staff members have been fully trained on their duties and responsibilities. Everyone involved has been informed of the student refund policies and requirements per the Title IV regulations. There have been procedures implemented to prevent this from being a repeat audit finding in the future. Anticipated Completion Date: July 2024

View Audit 340797

Finding 520904 (2024-005)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Questioned Costs Special Tests & Provisions

Name of Responsible Individual: Dylan J. Nowakowski, Director of Financial Aid Corrective Action: After Colleague was properly set up for Financial Aid for R2T4’s, the Director discovered that the calendars did not match the actual publicized academic calendar. Had the calendar been accurate with...

Name of Responsible Individual: Dylan J. Nowakowski, Director of Financial Aid Corrective Action: After Colleague was properly set up for Financial Aid for R2T4’s, the Director discovered that the calendars did not match the actual publicized academic calendar. Had the calendar been accurate with the correct dates of breaks of five days or more, then the R2T4 would have been accurate. The calendar in Colleague has now been corrected. For the years moving forward this will be verified before any R2T4 is calculated and submitted. All breaks that are five days or more are accurate. At Wheeling, we have a comprehensive R2T4 policy. This policy outlines how to count calendar days in a semester and provides clear instructions on what to do when a student withdraws during a break. Anticipated Completion Date: July 2024

View Audit 340797 Questioned Costs: $1

Finding 520902 (2024-011)

Material Weakness 2024

Wheeling Jesuit University INC

WV

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.430

FINDING 2024-011 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the records to substantiate the payroll costs were insufficient and lacking internal controls. Going forward the University plans to implement a strategic process ...

FINDING 2024-011 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the records to substantiate the payroll costs were insufficient and lacking internal controls. Going forward the University plans to implement a strategic process to document time and effort associated with research and development cluster and it’s federal grants. All employees that work with the Challenger Learning Center will continue to have their hours worked documented in the Paycom payroll software. Payroll is processed on a biweekly basis, and therefore on biweekly basis the payroll costs from the Challenger Learning Center will be reimbursed to the University from the various Challenger Learning Center bank accounts. This will be done as a percentage of time worked for the NIH Grant, the NASA Grant, and the general Challenger Learning Center functions. Anticipated Completion Date: June 2025

View Audit 340797 Questioned Costs: $1

Finding 520890 (2024-001)

Significant Deficiency 2024

MacOupin County Public Health Department

IL

Special Tests & Provisions Questioned Costs Internal Control / Segregation of Duties

Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" four (4) selections out of a sample size of forty (40) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, four (4) selections out of a ...

Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" four (4) selections out of a sample size of forty (40) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, four (4) selections out of a sample size of forty (40) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan: Management will ensure that all information is collected and input into the billing system correctly in order to avoid patients getting charged incorrect amounts for services. Antcipated Date of Completion: March 31, 2025. Name of Contact Person: Lori Sanson, CFO. Management's Response: Management is implementing weekly chart auditing of encounters from the prior week. These reviews will include a review of the client's financial information which includes assessment of the sliding fee scale paperwork completed, whether we have obtained proof of income, if the sliding fee was entered into the billing system, if the sliding fee adjustments are applied, if payment was collected, insurance information, and the client's balance. These audits will be sent to front office staff for corrections (if needed) or the CFO for review on a monthly basis. In addition, MCPHC Supervisors will obtain a monthly report of the clients that have not turned in proof of income in order to proactively reach out either by phone, email or mail and attempt to obtain the information.

View Audit 340762

Finding 520889 (2024-001)

Significant Deficiency 2024

Independence Place Cooperative of Willmar

MN

Questioned Costs Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 340755

Finding 520888 (2024-001)

Significant Deficiency 2024

Rainbow Fleet, Inc.

OK

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.512

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays e...

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays earlier in the audit process. Action Taken: Management agrees with the finding and will take steps to improve the timeliness of the audit process. Specifically, management has hired a new Chief Operating Officer and Chief Executive Officer who have been notified of the reporting requirements of the federal awards. Anticipated completion date: January 31, 2025 Name of contact person and title: Quisha Beardsley, Chief Executive Officer

View Audit 340750

Finding 520887 (2024-002)

Material Weakness 2024

Lutheran Social Services of Central Ohio Kensington Place, Inc.

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Condition: The Corporation did not deposit prior year surplus cash totaling $25,068 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact per...

Condition: The Corporation did not deposit prior year surplus cash totaling $25,068 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340745

Finding 520886 (2024-002)

Material Weakness 2024

Ashland Assisted Living, Inc. D/b/a Lutheran Village of Ashland

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Finding Number: 2024-002 Condition: The Corporation did not deposit prior year surplus cash totaling $56,345 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Acti...

Finding Number: 2024-002 Condition: The Corporation did not deposit prior year surplus cash totaling $56,345 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340744

Finding 520885 (2024-004)

Significant Deficiency 2024

Good Shepherd Real Estate Holding, LLC D/b/a the Good Shepherd

OH

HUD Housing Programs Reporting Significant Deficiency

Finding Number: 2024-004 Condition: The Corporation failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340743

Finding 520884 (2024-003)

Material Weakness 2024

Good Shepherd Real Estate Holding, LLC D/b/a the Good Shepherd

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Finding Number: 2024-003 Condition: The Corporation did not deposit prior year surplus cash totaling $19,794 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Acti...

Finding Number: 2024-003 Condition: The Corporation did not deposit prior year surplus cash totaling $19,794 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340743

Finding 520883 (2024-002)

Significant Deficiency 2024

Shawmet Homes, Inc.

MO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Recommendation: The Organization should review of its operating and maintenance policies and procedures, as well as review by the individuals monitoring the operating and maintenance of the property, to ensure that the necessary documentation showing that resident problems or concerns were responded...

Recommendation: The Organization should review of its operating and maintenance policies and procedures, as well as review by the individuals monitoring the operating and maintenance of the property, to ensure that the necessary documentation showing that resident problems or concerns were responded to in a timely manner is being completed. View of Responsible Officials and Corrective Actions: Shawmet Homes, Inc. has, and will continue to complete problems or concerns raised by tenants, and only failed to document timely completion within in our management system. The Organization has reviewed its staffing and implemented training, and periodic reviews of the work order system, to ensure that the documentation is being completed timely.

View Audit 340740

Finding 520881 (2024-001)

Significant Deficiency 2024

Youth Services Network, Inc.

IL

Internal Control / Segregation of Duties

Youth Services Network, Inc. has implemented several compensating controls but simply cannot justify the expense of hiring additional staff to reach the standard of segregation of duties suggested.

View Audit 340734

Finding 520877 (2024-002)

Material Weakness 2024

Vandalia Cusd 203

IL

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Payroll disbursements will align to the approved salary schedule.

View Audit 340710

Finding 520867 (2024-003)

Material Weakness 2024

Vandalia Cusd 203

IL

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Payroll disbursements will align to the approved salary schedule.

View Audit 340710

Finding 520834 (2024-007)

Significant Deficiency 2024

Alamance County, North Carolina

NC

Questioned Costs Cash Management Significant Deficiency

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and makin...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and making sure that information is accurate. Going forward supervisor will send out notification when IRS mileage reimbursement rates change and accounts payable staff will ensure the payable has the correct IRS mileage reimbursement rate listed. Proposed Completion Date: Immediate and ongoing.

View Audit 340657 Questioned Costs: $1

Finding 520826 (2024-006)

Material Weakness 2024

Alamance County, North Carolina

NC

Material Weakness Internal Control / Segregation of Duties Questioned Costs

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accur...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accuracy of entered information to minimize human error. All training sessions will continue to emphasize these expectations. The supervisor will conduct targeted second-party reviews in response to these findings to ensure accuracy. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520823 (2024-005)

Material Weakness 2024

Alamance County, North Carolina

NC

Material Weakness Internal Control / Segregation of Duties Questioned Costs

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Based on the audit results, it has been determined that three (3) files lacked a copy of the Responsible Individuals List, a mandatory document for completing adoptions in the State of North Carolina. Mana...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Based on the audit results, it has been determined that three (3) files lacked a copy of the Responsible Individuals List, a mandatory document for completing adoptions in the State of North Carolina. Management acknowledges this finding however further shares that without this form, the Clerk's Office is unable to process adoptions. Copies of these documents are available in the legal file; however, these records are sealed post-adoption and cannot be accessed by our agency. Other supporting documents, such as the Pre-Placement Assessment, were also provided to the auditors on these cases showing where it was documented that this requirement was met and that the individual’s information was processed and approved. This issue has been identified in previous audits, prompting the implementation of checks and balances to ensure sufficient copies are maintained at our office for future audits. Our staff now utilizes a review tool and undergoes a sign-off process, with oversight from supervisors to verify the presence of all required documents before filing and storage. Furthermore, the Department of Social Services (ACDSS) has been conducting a comprehensive internal audit of 100% of adoption cases to assess file completeness and address any deficiencies identified.It is important to note that older cases audited may still exhibit such deficiencies due to historical inadequacies in record keeping practices. Moving forward, we remain committed to maintaining rigorous standards of record management to prevent recurrence of these issues and ensure compliance with adoption processing requirements in North Carolina. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520822 (2024-004)

Material Weakness 2024

Alamance County, North Carolina

NC

Material Weakness Internal Control / Segregation of Duties Questioned Costs

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accur...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accuracy of entered information to minimize human error. All training sessions will continue to emphasize these expectations. The supervisor will conduct targeted second-party reviews in response to these findings to ensure accuracy. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520819 (2024-003)

Material Weakness 2024

Alamance County, North Carolina

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, recognizing that the reviewed sample includes casework from an earlier period when record-keeping practices were not as rigorous as they are today. Actions have alread...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, recognizing that the reviewed sample includes casework from an earlier period when record-keeping practices were not as rigorous as they are today. Actions have already been taken to enhance record-keeping among current staff and cases. Caseworkers will be reminded to ensure that all documents are properly filed and to double-check the accuracy of the information entered to minimize human error. Training sessions will emphasize the expectations for document retention and the importance of reviewing inputted information for accuracy. Additionally, supervisors and Quality Assurance staff will conduct targeted second-party reviews related to these findings. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520818 (2024-002)

Material Weakness 2024

Alamance County, North Carolina

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this audit finding. Caseworkers will receive a refresher training that includes reviewing case evidence and determinations to ensure the MAGI household is accurate. Supervisors and/...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management concurs with this audit finding. Caseworkers will receive a refresher training that includes reviewing case evidence and determinations to ensure the MAGI household is accurate. Supervisors and/or Quality Assurance staff will continue to perform monthly second party reviews on cases and will strengthen the procedures and tracking around this process. Identified issues will be promptly addressed with the team or individually to improve overall case management. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520816 (2024-003)

Significant Deficiency 2024

Paris Junior College

TX

Eligibility Internal Control / Segregation of Duties

Recommendations We recommend the College implement a review process of students' applications to ensure eligibility compliance requirements are met. Action Plan: Paris Junior College management will ensure that a comprehensive procedure is established and implemented to ensure compliance requireme...

Recommendations We recommend the College implement a review process of students' applications to ensure eligibility compliance requirements are met. Action Plan: Paris Junior College management will ensure that a comprehensive procedure is established and implemented to ensure compliance requirements are met. Contact Person: Lisa Elliott, VP Student Services Anticipated Completion Date: February 15, 2025

View Audit 340636

Finding 520794 (2024-002)

Material Weakness 2024

Blue Mountain Community College District

OR

Special Tests & Provisions Questioned Costs Material Weakness

The issue related to the Common Origination and Disbursement (COD) disbursement files continued to be an issue with our old Student Information System (SIS), Anthology. As of July 1, 2024, the College has moved to a new SIS, FOCAL. In addition, we moved to a standalone financial aid system, PowerFai...

The issue related to the Common Origination and Disbursement (COD) disbursement files continued to be an issue with our old Student Information System (SIS), Anthology. As of July 1, 2024, the College has moved to a new SIS, FOCAL. In addition, we moved to a standalone financial aid system, PowerFaids, that integrates with FOCAL. PowerFaids does not allow disbursement unless the Common Origination and Disbursement file from EdExpress is marked accordingly. Moving forward, disbursement files from COD will be reviewed daily and any disbursement records found to have errors will be resolved immediately. This will prevent future disbursement date errors with COD. Financial Aid moved to the PowerFaids system beginning with the Summer 2024 Term. With that move, new processes were implemented that will help to prevent this issue in the future.

View Audit 340598

Corrective Action Plans

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