Corrective Action Plans

Finding 390198 (2023-001)

Significant Deficiency 2023

St. Lukes Health Network, Inc. and Controlled Entities

PA

Student Financial Aid Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal ...

2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network has controls for the student financial aid program, monitored by the Student Financial Aid Office. The Network agrees with the finding regarding the retention of support and documentation of the reviews and approvals in the financial aid process. Going forward the Network will enhance the documentation and retention of support of proper review and approval that will evidence the appropriate segregation of duties. The Network is implementing this process beginning in Q4 of FY2024. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.

View Audit 301103

Finding 390168 (2023-002)

Material Weakness 2023

Altus Independent School District #18

OK

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking

Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.

View Audit 301082

Finding 390167 (2023-001)

Material Weakness 2023

Altus Independent School District #18

OK

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking

Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on any future federal awards. Weekly payroll reports will be reviewed with vendors to ensure that federal rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.

View Audit 301082

Finding 390163 (2023-005)

Material Weakness 2023

Yukon Flats School District

AK

Cash Management Material Weakness Reporting

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calenda...

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calendar developed by ALASBO which addresses all reporting requirements for the school districts in Alaska. Proposed Completion Date: March 31, 2024

View Audit 301080

Finding 390157 (2023-002)

Significant Deficiency 2023

City of Daly City

CA

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

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Departm...

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0010 COVID-19 - B-20-MW-06-0010 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Betsy ZoBell, Housing and Community Development Manager • Corrective Action Plan: ECD staff will perform periodic review of estimates to confirm that payroll allocations are supported by timesheet documentation of actual hours worked. • Anticipated Completion Date: 06/30/24

View Audit 301060

Finding 390151 (2023-002)

Significant Deficiency 2023

Vermont Adult Learning, Inc.

VT

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding # 2023 -002 Issue: During our audit procedures we identified instances where there was no documented rate approval or pay rate support within personnel files. Pay rates and pay rate changes should be reviewed and approved by department supervisors and human resource director at the time o...

Finding # 2023 -002 Issue: During our audit procedures we identified instances where there was no documented rate approval or pay rate support within personnel files. Pay rates and pay rate changes should be reviewed and approved by department supervisors and human resource director at the time of pay changes and documented in personnel files. Root Cause: The Organization is not properly following the internal controls in place over the documentation of such pay rate changes. Corrective Action Plan: ● The Organization has discussed internally how to more accurately and efficiently submit, sign and record pay rates and pay rate changes. The Human Resources department, as well as all supervisors are dedicated to retaining accurate and complete personnel records. The Organization will send each employee a letter when their raise comes up that documents their old rate and new rate. This letter will be signed by the employee, then the Supervisor, as well as the HR Director. Once all three signatures are obtained, HR will send a final, signed copy to the supervisor, and will keep a copy in a secure, central location that is accessible to the Supervisors and Directors. Timeline: This will be implemented as soon as possible Person Responsible for Corrective Action Plan: Joe Przyperhart, Program Director/Interim Executive Director, David Justice, Program Director/Interim Executive Director, Human Resources Director, Grant Managers and Regional Directors will oversee changes to ensure all payroll rate changes are reviewed, approved and appropriately filed in a secure location.

View Audit 301059

Finding 390147 (2023-001)

Significant Deficiency 2023

Vermont Adult Learning, Inc.

VT

Procurement, Suspension & Debarment Significant Deficiency Matching / Level of Effort / Earmarking

Finding # 2023-001 Issue: During our audit procedures we identified instances where there was no documented approval of invoices over expense transactions. Expenses should be reviewed and approved by someone other than the purchaser. Root Cause: The Organization is not properly following the in...

Finding # 2023-001 Issue: During our audit procedures we identified instances where there was no documented approval of invoices over expense transactions. Expenses should be reviewed and approved by someone other than the purchaser. Root Cause: The Organization is not properly following the internal controls in place over the approval of such expense transactions. Corrective Action Plan: We are committed to ensuring that we have approval of all expense transactions. To that end we have: ● VAL implemented procedures that all expenses must be accompanied by a purchase approval form for approval before the payment occurs. The purchase approval form is initiated by the purchaser, then signed by a manager or director and is submitted with the invoice or credit card receipt to Bill.com (A/P) or Dext (CC transactions) for payment and/or documentation retention. Multiple levels of additional approval are documented and retained in Bill.com (A/P). Purchases through vendor websites also include a level of approval (for example Staples and Amazon). In these cases, staff create an order and submit it for approval. The order is not processed until the Office Administrator approves every order. Invoices from these vendors still go through the regular approval process. There is just an extra layer of approval to ensure accuracy in reporting. ● Recurring expenses - The purchase approval process is also initiated for the initial payment of a recurring expense, noting that the expense will be a recurring charge. When expenses occur after the initial expense, any documentation related to the expense will be saved, but no approval form is required for future expenses as long as the amount or coding doesn’t change. This includes, but is not limited to, monthly lease payments, job search subscriptions, parking subscriptions, health/dental/vision/FSA expenses, etc. Timeline: This updated process has been implemented as of April 2023. Staff and management have been more diligent regarding including purchase approval forms to all expenses incurred. VAL has also verified that all expenses are reviewed for accuracy by managers, directors, and the outsourced accounting firm. Person Responsible for Corrective Action Plan: Joe Przyperhart, Program Director/Interim Executive Director, David Justice, Program Director/Interim Executive Director, Grant Managers and Regional Directors will oversee changes to ensure all expenses include the appropriate approval documentation.

View Audit 301059

Finding 390146 (2023-002)

Material Weakness 2023

Health Care for All, INC

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Given the Organization’s lack of experience with federal awards, Management was not familiar with the accounting requirements for expenses allocated to federal grant programs. In particular, there was a lack of familiarity with respect to the limitations on indirect cost rate application on subreci...

Given the Organization’s lack of experience with federal awards, Management was not familiar with the accounting requirements for expenses allocated to federal grant programs. In particular, there was a lack of familiarity with respect to the limitations on indirect cost rate application on subrecipient disbursements. Moving forward, management will ensure that it properly allocate expenses in accordance with Uniform Guidance Regulations. In addition, management plans to work closely with the federal passthrough entity to ensure that overbilled amounts are returned during the fiscal year ending June 30, 2024

View Audit 301052 Questioned Costs: $1

Finding 390145 (2023-001)

Significant Deficiency 2023

Health Care for All, INC

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

View Audit 301052

Finding 390138 (2023-002)

Material Weakness 2023

Barnes-Kasson County Hospital

PA

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,0...

Finding 2023-002 Condition The Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Hospital erroneously entered information into the lost revenue calculation, resulting in lost revenues being understated $1,020,030. The Hospital reported lost revenues amounting to $999,172 on distributions totaling $1,177,041. The Hospital had excess lost revenues from previous periods available to be used through June 30, 2023 amounting to $5,406,884. The Hospital also reported expenses of $907,051. Corrective Action Plan Corrective Action Planned: The Hospital will undertake a review of its internal control policies and procedures surrounding the reporting on federal grant activities and add additional layers of review where necessary to ensure future reporting is accurate. Name of Contact Person Responsible for Corrective Action: Kelli Kane, Chief Financial Officer Anticipated Completion Date: April 15, 2024

View Audit 301031

Finding 390135 (2023-101)

Material Weakness 2023

Gila County

AZ

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Assistance Listings number and program name: 21.027 COVID-19 Corona Virus State and Local Fiscal Recovery Fund Contact: Maryn Belling Anticipated completion date: June 30, 2024 Corrective Action Plan: The County will develop, implement, and maintain procedures requiring both the performance & doc...

Assistance Listings number and program name: 21.027 COVID-19 Corona Virus State and Local Fiscal Recovery Fund Contact: Maryn Belling Anticipated completion date: June 30, 2024 Corrective Action Plan: The County will develop, implement, and maintain procedures requiring both the performance & documentation of independent review and approval of all federal program reports prior to submitting them to the federal agency to ensure the reports are accurate, agree to County records, and contain only allowable expenditures. Program expenditures will be reconciled to the County’s accounting records. The County’s previous corrective action plan stated “Errors identified will be reported to the federal agency in adjusted or resubmitted reports” however the Federal Reporting interface lacks capacity for resubmitted reports. The adjusted reports resulted in the understatement and overstatement amounts noted in Federal Award Finding 2023-101. Departmental training will be provided for staff responsible for preparing and reviewing reports for both data management, compliance with Uniform Guidance, 2 Code of Federal Regulations (CFR) §200.510, and adherence to County’s policies and procedures.

View Audit 301026

Finding 390121 (2023-003)

Significant Deficiency 2023

Integrated Living, Inc.

KS

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

March 26, 2024 HUD Service Audit Director Kansas City, Kansas Integrated Living, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. SSC CPAs, P.A. 58525 SW 29th St, Suite 100 Topeka, Kansas 66614 Audit period: Year ended June 30, 2023 The findings ...

March 26, 2024 HUD Service Audit Director Kansas City, Kansas Integrated Living, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. SSC CPAs, P.A. 58525 SW 29th St, Suite 100 Topeka, Kansas 66614 Audit period: Year ended June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section I of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS-FINANCIAL STATEMENT AUDIT 2023‐001 Internal Controls over Financial Statement Presentation (Material Weakness) Recommendation: The Board of Directors and management should review the impact of the current year adjustments on the financial reporting process. Once this review is complete, the Organization should then perform a risk assessment to determine the best way to implement appropriate internal controls over financial reporting to ensure conformity with U.S. GAAP. Action Taken (Unaudited): Management is in the process of updating its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. John Griffin, CFO of COF Training Services, Inc. (Management Agent of Integrated Living, Inc.) is responsible for this corrective action. Anticipated completion date is June 30, 2024. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS 2023‐002 Review and Approval of Project Expenditures (Significant Deficiency) Department of Housing and Urban Development Section 811 Supportive Housing for Person with Disabilities, Assistance Listing Number 14.181 Recommendation: The Organization should obtain proper approval of all project expenditures and that evidence of that approval is documented and maintained.. Action Taken (Unaudited): Management is in the process of updating its control procedures to ensure proper approval of all project expenditures. John Griffin, CFO of COF Training Services, Inc. (Management Agent of Integrated Living, Inc.) is responsible for this corrective action. Anticipated completion date is June 30, 2024. 2023‐003 Written Procedures of Internal Control over Compliance (Significant Deficiency) Department of Housing and Urban Development Section 811 Supportive Housing for Person with Disabilities, Assistance Listing Number 14.181 Recommendation: The Organization should develop written policies for the internal control over compliance of federal awards. Action Taken (Unaudited): Management is in the process of updating its control procedures to include proper written policies for the internal control over compliance of federal awards John Griffin, CFO of COF Training Services, Inc. (Management Agent of Integrated Living, Inc.) is responsible for this corrective action. Anticipated completion date is June 30, 2024. If HUD has questions regarding this plan, please call Patrick Gardner at 785-242-5035. Sincerely yours, Patrick Gardner CEO, COF Training Services, Inc. (Management Agent of Integrated Living, Inc.)

View Audit 301005

Finding 390120 (2023-002)

Significant Deficiency 2023

Integrated Living, Inc.

KS

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

March 26, 2024 HUD Service Audit Director Kansas City, Kansas Integrated Living, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. SSC CPAs, P.A. 58525 SW 29th St, Suite 100 Topeka, Kansas 66614 Audit period: Year ended June 30, 2023 The findings ...

March 26, 2024 HUD Service Audit Director Kansas City, Kansas Integrated Living, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. SSC CPAs, P.A. 58525 SW 29th St, Suite 100 Topeka, Kansas 66614 Audit period: Year ended June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section I of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS-FINANCIAL STATEMENT AUDIT 2023‐001 Internal Controls over Financial Statement Presentation (Material Weakness) Recommendation: The Board of Directors and management should review the impact of the current year adjustments on the financial reporting process. Once this review is complete, the Organization should then perform a risk assessment to determine the best way to implement appropriate internal controls over financial reporting to ensure conformity with U.S. GAAP. Action Taken (Unaudited): Management is in the process of updating its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. John Griffin, CFO of COF Training Services, Inc. (Management Agent of Integrated Living, Inc.) is responsible for this corrective action. Anticipated completion date is June 30, 2024. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS 2023‐002 Review and Approval of Project Expenditures (Significant Deficiency) Department of Housing and Urban Development Section 811 Supportive Housing for Person with Disabilities, Assistance Listing Number 14.181 Recommendation: The Organization should obtain proper approval of all project expenditures and that evidence of that approval is documented and maintained.. Action Taken (Unaudited): Management is in the process of updating its control procedures to ensure proper approval of all project expenditures. John Griffin, CFO of COF Training Services, Inc. (Management Agent of Integrated Living, Inc.) is responsible for this corrective action. Anticipated completion date is June 30, 2024. 2023‐003 Written Procedures of Internal Control over Compliance (Significant Deficiency) Department of Housing and Urban Development Section 811 Supportive Housing for Person with Disabilities, Assistance Listing Number 14.181 Recommendation: The Organization should develop written policies for the internal control over compliance of federal awards. Action Taken (Unaudited): Management is in the process of updating its control procedures to include proper written policies for the internal control over compliance of federal awards John Griffin, CFO of COF Training Services, Inc. (Management Agent of Integrated Living, Inc.) is responsible for this corrective action. Anticipated completion date is June 30, 2024. If HUD has questions regarding this plan, please call Patrick Gardner at 785-242-5035. Sincerely yours, Patrick Gardner CEO, COF Training Services, Inc. (Management Agent of Integrated Living, Inc.)

View Audit 301005

Finding 390109 (2023-001)

Significant Deficiency 2023

City of San Diego

CA

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

Reference Number: 2023-001 Audit Finding: Other Compliance Corrective Action: The Public Utilities Department has re-evaluated the internal procedures and practices of maintaining compliance documentation. Third party vendors will no longer serve as an archive for notification documentation. All not...

Reference Number: 2023-001 Audit Finding: Other Compliance Corrective Action: The Public Utilities Department has re-evaluated the internal procedures and practices of maintaining compliance documentation. Third party vendors will no longer serve as an archive for notification documentation. All notification receipts and various forms of verification will be saved in house, on the City of San Diego’s network. This corrective action was set in place as of March 28, 2023, based on findings from the water arrearages program audit. The sewer arrearages program was also completed prior to the original corrective action plan date of March 28, 2023. This was the same finding for both the water and sewer arrearage program audits. Moving forward with this action on a continual basis, once email notifications are sent to customers using an external service provider, notification confirmations will be immediately archived at the City of San Diego. The acknowledgement must state that the credited amount is being provided through funding from the State Water Resources Control Board using federal American Rescue Plan Act (ARPA) funds. This affords the City full control and oversight of the verification process for all future noticing. All available notification verifications from the third-party vendor will be downloaded and saved to the City network for future inquiries. Furthermore, internal controls will be enhanced to ensure notification verification compliance. Upon notification to customers, the Billing and Financial Analytics Program Coordinator will oversee the immediate archiving of all confirmations of emails sent to customers using an external service provider. Once complete, the Billing and Financial Analytics Program Coordinator will notify the Program Manager, who will in turn, perform a secondary review of all notifications against the verification documentation to ensure accuracy. At this point, a third level of approval will be added, as the Public Utilities Customer Support Deputy Director will provide a final level review. Once complete, these documents will be saved for a minimum of five years, per the City of San Diego’s retention policy. Implementation Date: 03/28/2023 Contact: Tracy Morales Interim Deputy Director

View Audit 300999

Finding 390087 (2023-001)

Significant Deficiency 2023

University of Arkansas for Medical Sciences

AR

Reporting Internal Control / Segregation of Duties

Corrective Action Plan Finding 2023-001 Due to the prior year finding, management set a goal to ensure reporting deadlines are met by hiring an additional grants accounting staff member dedicated to monitor the head start program regulations and ensure reports are completed and filed timely. Grants...

Corrective Action Plan Finding 2023-001 Due to the prior year finding, management set a goal to ensure reporting deadlines are met by hiring an additional grants accounting staff member dedicated to monitor the head start program regulations and ensure reports are completed and filed timely. Grants accounting staff planned to utilize checklist functionality in the new financial system that will send required task notifications prior to reporting due dates to assist in meeting reporting deadlines. A new staff member was hired in July 2023. The responsibilities of the new staff member required several months of training and additional time to reconcile the head start accounts causing the January 30, 2023, report to be filed 3 days late. New processes have been implemented where the staff member assigned to the head start program meets weekly with the head start finance manager and director to discuss expenses allocated to the grants, assign tasks to be complete each week, and discuss reporting needs and deadlines. The new implemented processes have proven to assist in proper oversight and accurate financial management of the grants and allowed us to meet the last reporting deadline in November 2023. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: Implemented

View Audit 300960

Finding 390061 (2023-003)

Material Weakness 2023

Ohio Medical Transportation, Inc. D/b/a Medflight of Ohio

OH

Material Weakness Reporting Matching / Level of Effort / Earmarking

Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and ...

Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure data uploaded into the portal agrees to underlying supporting documentation. Contact person responsible for corrective action: Joe Abel, Chief Financial Officer Anticipated Completion Date: 4/30/2023

View Audit 300923

Finding 390051 (2023-001)

Significant Deficiency 2023

Portland State University

OR

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

Recommendation: We recommend that the University implement processes and/or internal controls that ensure that a student has completed entrance counseling prior to disbursing Direct Loans proceeds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Recommendation: We recommend that the University implement processes and/or internal controls that ensure that a student has completed entrance counseling prior to disbursing Direct Loans proceeds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The error was caused by an abrupt resignation of loan processing staff and a lack of redundancy in critical processing areas. A staff member who was new to loan administration originated a loan then disbursed it to the student the moment it returned from COD. This rapid processing was in response to the student’s dire need for housing funding; however, the expedited process inadvertently circumvented the Banner system’s safeguards. This previously unknown issue has been resolved with the following systems updates: 1. Improved training and documentation 2. The previous system relied on RRAAREQ to prevent disbursement; however, the new system has a secondary and tertiary check that prevents disbursement. Both the entrance counseling tick box on RLADLOR and a positive indicator on the table that captures raw entrance counseling data (RPILECS) must align for a loan disbursement. Name of the contact person responsible for corrective action: Elijah Herr, Director of Financial Aid Planned completion date for corrective action plan: March 2024

View Audit 300906 Questioned Costs: $1

Finding 390049 (2023-002)

Significant Deficiency 2023

Portland State University

OR

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates reported to NSLDS agree to the enrollment effective dates per the University’s records. Explanation of disagreement with audi...

Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates reported to NSLDS agree to the enrollment effective dates per the University’s records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: It appears that the erroneous enrollment status effective date reported is equal to the certification date for the enrollment file that was sent to the National Student Clearinghouse (NSC). We are researching how the certification date may have been substituted as the enrollment status effective date. Name of the contact person responsible for corrective action: Nicolle DuPont, Associate Registrar Planned completion date for corrective action plan: April 2024

View Audit 300906

Finding 390048 (2023-003)

Significant Deficiency 2023

Portland State University

OR

Student Financial Aid Subrecipient Monitoring Internal Control / Segregation of Duties

Recommendation: We recommend that the University strengthen its internal controls over monitoring the academic engagement for students that are enrolled in distance education courses at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...

Recommendation: We recommend that the University strengthen its internal controls over monitoring the academic engagement for students that are enrolled in distance education courses at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The University had already identified this weakness prior to the Single Audit. To address this weakness, Portland State University has implemented a robust Initiation of Attendance protocol that is required of every instructor. Faculty were informed of: 1) Federal regulations related to initiation of attendance. 2) The standards used for documenting academic engagement in an online environment. 3) The method by which the instructor positively indicates that an online student has academically engaged in the course. The University has provided written policies on its website and engaged in a vigorous communication plan with both faculty and students. Compliance with the new policy is monitored through weekly reporting, and instructors who have not documented the initiation of attendance are referred to their dean, chair or department head. Prior to any reduction in Title IV aid, students are notified of any missing documentation and encouraged to speak with their instructors immediately. Last, reconciliation reports are monitored by the financial aid office for discrepancies and any conflicting information is resolved by contacting the instructor. Name of the contact person responsible for corrective action: Elijah Herr, Director of Student Financial Aid, Cindy Baccar, Associate Vice Provost & University Registrar and Karenna Wait, Director of Enterprise Applications. Planned completion date for corrective action plan: September 2023

View Audit 300906

Finding 389997 (2023-002)

Significant Deficiency 2023

Washington County Commission on Aging, Inc.

MD

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

NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the proc...

NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the procedures involved in recording employee time on timesheets and transferring this data to the financial management system. The CFO will immediately evaluate the need for additional controls to ensure accurate recording of time charged to programs as reflected on the employee's timesheet. The CFO will immediately implement new processes that establish checks and balances to verify that the programs charged in the general ledger align with the time recorded by the employees and is verified by their supervisor. The CFO and HR director will provide training sessions to all staff and new hires on the importance of accurately capturing and recording payroll costs by April 30, 2024. The CEO will immediately provide training to the CFO and staff accountant on the significance of aligning time charged with the programs designated in the general ledger for proper grant award billing. The CFO will conduct periodic reviews of payroll transactions to identify any discrepancies or irregularities promptly and take action immediately upon identification of such. These reviews will continue through FY 2025.

View Audit 300903

Finding 389992 (2023-002)

None 2023

Queens University of Charlotte

NC

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

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the student for...

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the student for both the fall 2022 and spring 2023 semesters. We can document the spring 2023 loan disbursement notification was sent but are unable to document the date. Our internal processes dictate that the notification would normally be sent on the date of disbursement. We will develop and implement additional controls to effectively capture a student’s disbursement notification to ensure that both a record of the notification and the date are maintained. Anticipated Completion Date: August 15, 2024

View Audit 300901

Finding 389986 (2023-004)

Significant Deficiency 2023

Queens University of Charlotte

NC

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

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. The break days for fall 2022 were not properly calculated to...

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. The break days for fall 2022 were not properly calculated to include a break of 5 days. We will develop and implement a process within Student Financial Services to audit all R2T4 records for accuracy, completeness, and consistency regarding length of academic periods. Anticipated Completion Date: August 15, 2024

View Audit 300901

Finding 389984 (2023-001)

Significant Deficiency 2023

Neighborhood Health Care, INC

OH

Questioned Costs Internal Control / Segregation of Duties

NFP concurs with this finding and notes the $52,982 of questioned costs were written off to the wrong adjustment code due to the automated write-off with the patient software. NFP identified the issue in December of 2022 and the Vice President of Compliance and Chief Financial Officer performed a r...

NFP concurs with this finding and notes the $52,982 of questioned costs were written off to the wrong adjustment code due to the automated write-off with the patient software. NFP identified the issue in December of 2022 and the Vice President of Compliance and Chief Financial Officer performed a root cause analysis as to the starting point. Management corrected the write-off with the patient software that was causing the automated adjustments when initially identified. Management will continue to audit and review the automated write-off with the patient software on a quarterly/monthly basis (as determined) going forward as well as implementing procedures to ensure the sliding scale eligible visits are properly documented and adjusted in the billing system.

View Audit 300892 Questioned Costs: $1

Finding 389983 (2023-002)

None 2023

Washington Adventist University

MD

Questioned Costs Special Tests & Provisions Student Financial Aid

I will ensure the Financial Aid Office works closely with the Accounts Payables department to monitor that all Title IV refund checks have been cashed after 30 days of issuance of the refund. If a check has not been cashed a new check will be reissued immediately. If, after 30 days of the reissuance...

I will ensure the Financial Aid Office works closely with the Accounts Payables department to monitor that all Title IV refund checks have been cashed after 30 days of issuance of the refund. If a check has not been cashed a new check will be reissued immediately. If, after 30 days of the reissuance, the check has not been cashed then the funds will be returned to the Department of Education within the mandated 45-day period.

View Audit 300889 Questioned Costs: $1

Finding 389980 (2023-001)

Material Weakness 2023

Amber-Pocasset School District I-128

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

Beginning immediately the District will develop internal controls to meet the requirements of the Davis-Bacon Act that ensure any time federal awards are used on construction that compliance with contracts, including inserting the prevailing wage clauses and ensuring that federal wage rates and frin...

Beginning immediately the District will develop internal controls to meet the requirements of the Davis-Bacon Act that ensure any time federal awards are used on construction that compliance with contracts, including inserting the prevailing wage clauses and ensuring that federal wage rates and fringes are met by an effective monitoring process which includes collecting and reviewing weekly certified payroll reports from the contractor or subcontractor. The District will also ensure that all items are posted at the work site to ensure compliance.

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Corrective Action Plans

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