Corrective Action Plans

Finding 390478 (2023-006)

Material Weakness 2023

NH

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

BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance ...

BEA will evaluate existing internal controls in place to ensure that the precision level of the control is such that it would detect an error in the expenditures reported in comparison to the expenditures incurred within the general ledger, account for precision level control when changing guidance exists, and that all documentation used to support the amounts reported on the federal report are properly maintained. Condition A has been completed. In January 2024, BEA evaluated internal controls related to the review and approval of expenditures. The following additional reconciliation step was added to the processes of preparation of expenditure draws and reporting preparation: • Broadband program Accountant II performs a data extract from NHFirst and reconciles the drawdown calculation totals as well as “dashboard” reporting totals to the NHFirst data extract to confirm accuracy of all data points. This second data validation step has been added to ensure all expenditures recorded in NHFirst are evaluated against program guidelines, submitted for reimbursement and included on required reports. Condition B & C to be completed no later than 12/31/2024.

View Audit 301259

Finding 390475 (2023-003)

Material Weakness 2023

State of New Hampshire

NH

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.303

In order to meet the segregation of duties, the Department will explore the need to create a position to ensure requisite segregation of duties requirements. With regard to the segregation of duties, the SF-270 is required form that DMAVS submits to the National Guard Appendix Program Manager for re...

In order to meet the segregation of duties, the Department will explore the need to create a position to ensure requisite segregation of duties requirements. With regard to the segregation of duties, the SF-270 is required form that DMAVS submits to the National Guard Appendix Program Manager for reimbursement with all back up documentation. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense on behalf of DMAVS to request the cash draw. Prior to the submission of reimbursement of any funds, each billing and invoice is reviewed, entered into a ledger and reconciled by three members of the accounting team. Once reconciled, the SF-270 is prepared and signed by the Financial Administrator. The SF-270 is then submitted to the appendix program manager for concurrence and then to the federal fiscal agent (USPFO) for approval. No funds are drawn down until approved by the USPFO. If this is not a satisfactory level of review, the department will request a new position to ensure that there the business function has the proper level of staffing to meet the requirements for segregation of duties.

View Audit 301259

Finding 390474 (2023-002)

Material Weakness 2023

State of New Hampshire

NH

Internal Control / Segregation of Duties Cash Management Material Weakness § 200.303

For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all tr...

For clarity the Department will create a redundant manual ledger that duplicates the functions of the current ledger and Detailed Transaction Register (DTR). DMAVS has existing policies and procedures in place to track all federal funds, state funds and mixed funds, and uses spreadsheets for all transactions that reconciles every month to NH First Detail Transaction Register (DTR), Federal Fund tracking sheet, and Federal reimbursement tracking sheet with backup documents. The tracking sheet for the federal register is not intended to account for the state share of billing. The state share is accurately accounted for in the DTR, the cumulative accounting in the SF-270 and associated back up documentation. Supporting documentation to substantiate the accuracy of lines a, c, e, and f is in the DTR, the cumulative accounting of each SF-270, the supporting documentation sent with the billing to the Federal Government, and Year-end Agency Report for Federal Awards. This includes reconciliation and analysis of SADB expenditures and revenues to the Statement of Appropriations by each Program Accounting Unit. The SF-270 form is continuous cumulative data that starts Oct 1st and runs through the end of that Federal Fiscal Year. The SF-270 is the required federal form DMAVS submits to the Federal National Guard Appendix Program Manager for reimbursement. Back up documentation is submitted with the SF-270. The National Guard Appendix Program Manager, National Guard Grants Officer Representative, and National Guard United States Property Fiscal Officer (USPFO)/controller located in Concord, NH review, sign and submit the form to the Department of Defense to affect the cash draw. DMAVS does not unilaterally make cash draws to the federal government. The USPFO, who is substantially involved provides an independent review and reconciles any discrepancies prior to approving any requests for reimbursement. One possible explanation for the finding is that the selected test works were not continuous.

View Audit 301259

Finding 390445 (2023-004)

Significant Deficiency 2023

Oregon Tech

OR

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.038 Recommendation: We recommend that they assign the loans back to the Department of Education or have the students resign the loans via Electronic MPN or Paper MPN and retain those in the proper manner. Explanation of disagreement ...

Student Financial Assistance Cluster – Assistance Listing No. 84.038 Recommendation: We recommend that they assign the loans back to the Department of Education or have the students resign the loans via Electronic MPN or Paper MPN and retain those in the proper manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure all student loan documentation is maintained per the U.S. Department of Education policies. Management will assign the respective loans back to the Department of Education as to be in compliance with U.S. Department of Education requirements. Name(s) of the contact person(s) responsible for corrective action: Karissa Sultan Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390442 (2023-003)

Significant Deficiency 2023

Oregon Tech

OR

Significant Deficiency Internal Control / Segregation of Duties § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: We recommend that the University enhance its policies and procedures to ensure required contracts and contract components are provided to the U.S. Department of Education. Explanation of disagreeme...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: We recommend that the University enhance its policies and procedures to ensure required contracts and contract components are provided to the U.S. Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure all required information is provided to the U.S. Department of Education. Additionally, Management will work to ensure that the required contract URL is provided the U.S. Department of Education, following the agency’s requirements. Name(s) of the contact person(s) responsible for corrective action: Karissa Sultan Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390441 (2023-002)

Significant Deficiency 2023

Oregon Tech

OR

Significant Deficiency Internal Control / Segregation of Duties § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: CLA recommends that the University enhance its policies and procedures regarding stale-dated check escheatment to ensure that the funds are returned to the appropriate program within 240 days from the date of issue...

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: CLA recommends that the University enhance its policies and procedures regarding stale-dated check escheatment to ensure that the funds are returned to the appropriate program within 240 days from the date of issue. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures regarding stale-dated federal student financial aid outstanding checks. Management will implement additional procedures, returning checks issued directly by the University that stale-dated, similar to policies and procedures followed by the University’s third-party credit balance refund vendor. As part of this procedure, management will engage in student communication and outreach, similar to the University’s regular escheatment procedures. Management believes that a consistent practice between University-issued checks and third-party credit balance refund vendor-issued checks is in the best interest of students while also adhering to U.S. Department of Education timing requirements. Name(s) of the contact person(s) responsible for corrective action: Karissa Sultan Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390438 (2023-001)

Significant Deficiency 2023

Oregon Tech

OR

Student Financial Aid Subrecipient Monitoring Reporting § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting i...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007 Recommendation: CLA recommends that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in additional staff training and is committed to consistent application of current policies and procedures to ensure enrollment reporting and monitoring of third-party service providers results in accurate and timely reporting by the third-party service provider. While the third-party service provider has a national monopoly on enrollment reporting, with other institutions of higher education also facing similar reporting issues by the third-party service provider, Management believes that enhanced training and internal procedures over enrollment reporting will mitigate accuracy and timeliness errors made by the third party service provider, resulting in the University meeting U.S. Department of Education requirements. Name(s) of the contact person(s) responsible for corrective action: Ashlie Pence Planned completion date for corrective action plan: June 30, 2024

View Audit 301235

Finding 390429 (2023-005)

Material Weakness 2023

Housing Authority of the City of Salina

KS

Reporting Internal Control / Segregation of Duties

To work with fee accountant in making the corrections necessary and recommended by the auditor.

View Audit 301229

Finding 390424 (2023-007)

Significant Deficiency 2023

Delaware State University

DE

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2023-007 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policie...

2023-007 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion – Federal Assistance Listing Nos. 84.425E and 84.425F - Reporting Recommendation: We recommend the University enhances its procedures, controls, and review policies around HEERF reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Business & Finance will populate and upload the quarterly CARES HBCU and Institutional reports by the 10th day after the end of each calendar quarter. The Office of Student Accounts will create and upload the quarterly CARES Student Portion reports by the 10th day after the end of each calendar quarter. Name(s) of the contact person(s) responsible for corrective action: Assistant Controller, Clifton Smith, II & Executive Director of Student Accounts, Carold Boyer-Yancy. Planned completion date for corrective action plan: May 2024

View Audit 301226

Finding 390416 (2023-009)

Material Weakness 2023

Delaware State University

DE

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation o...

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Information Technology is reviewing the written policies and procedures needed to safeguard the University’s applications and data. This includes all 3rd party developed/ implemented applications as well. Name(s) of the contact person(s) responsible for corrective action: Executive Director of Network Services, Russel Weaver & VP/ Chief Information Officer, Darrell McMillion. Planned completion date for corrective action plan: June 2024

View Audit 301226

Finding 390415 (2023-006)

Significant Deficiency 2023

Delaware State University

DE

Significant Deficiency Internal Control / Segregation of Duties

2023-006 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, and 84.268 – Outstanding Refund Checks Recommendation: We recommend the University review policies and procedures around outstanding student refund checks to ensure the checks are returned to the ED prior...

2023-006 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, and 84.268 – Outstanding Refund Checks Recommendation: We recommend the University review policies and procedures around outstanding student refund checks to ensure the checks are returned to the ED prior to the 240-day deadline. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Business & Finance will review the procedures and work collaboratively with teams to investigate, research, and resolve any outstanding refunds. Name(s) of the contact person(s) responsible for corrective action: Executive Director of Student Accounts, Carold Boyer-Yancy. Planned completion date for corrective action plan: June 2024

View Audit 301226

Finding 390410 (2023-002)

Significant Deficiency 2023

Metropolitan Community College Area

NE

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster Recommendation: We recommend the College reviews their policies to ensure all requirements from the Department of Education are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findi...

Student Financial Assistance Cluster Recommendation: We recommend the College reviews their policies to ensure all requirements from the Department of Education are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MCC SAP policy has been corrected and updated to meet federal requirements on calculating the pace a student must progress through their educational program. Moving forward Financial Aid Management will review their policies and procedures annually to ensure that we are meeting all Department of Education SAP requirements. Name(s) of the contact person(s) responsible for corrective action: Kelsey Scott Planned completion date for corrective action plan: Spring 2024

View Audit 301214

Finding 390408 (2023-004)

Material Weakness 2023

Hunters Point Boarding School, Inc.

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

Finding Number: 2023‐004 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Faron Logan, Business Manager Anticipated Completion Date: April 30, 2024 Planned Corrective Action: The Business Manager will imme...

Finding Number: 2023‐004 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Faron Logan, Business Manager Anticipated Completion Date: April 30, 2024 Planned Corrective Action: The Business Manager will immediately ensure that all payroll withholdings/ deductions will be processed properly along with all stipends. This will correct the quarterly Form 941 that will be filed by the Business Manager. All time sheets will be reviewed by Business Manager to make sure all employees hours are correctly paid.

View Audit 301207

Finding 390379 (2023-104)

Material Weakness 2023

Coconino County

AZ

Reporting Internal Control / Segregation of Duties § 200.303

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completi...

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration department acknowledges the required financial reports were not all submitted during FY23. The Department did not have a tracking mechanism in place to ensure that all staff were aware of the status of report submission. Additionally, due to recent turnover, the Department did not have staff trained to complete the reports. The Department will complete and submit missing federal financial reports according to the direction provided by the Arizona Department of Economic Security. The County will ensure that the staff responsible for grant reporting have the knowledge and skills necessary to do so in compliance with federal requirements and grant accounting practices. The County has implemented a mechanism to monitor and track reporting due dates and oversee reports to ensure accuracy.

View Audit 301196

Finding 390376 (2023-101)

Material Weakness 2023

Coconino County

AZ

Internal Control / Segregation of Duties Reporting § 200.301 § 200.302 § 200.303

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual fi...

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual financial and performance reports were not filed in accordance with the contract. The cash draw reports were completed for the award according to the contractual requirements. Therefore, the federal agency was aware of all expenditures made under the award. The FCD will submit all missing annual financial and performance reports. With assistance from the Finance Department, the FCD will develop procedures to ensure all reporting requirements are met. These procedures will include internal timelines, designated roles and responsibilities, and a tracking mechanism. Additionally, fiscal capacity will be created through the training of an additional staff member in reporting to serve as backup so contractual reporting requirements can be fulfilled when unforeseen challenges arise such as declared emergencies and flood events.

View Audit 301196

Finding 390371 (2023-010)

Significant Deficiency 2023

City of Amsterdam, New York

NY

Internal Control / Segregation of Duties

The City is transitioning to a new financial software program that will soon resolve this issue. An electronic approval level is being programmed so that payroll cannot be processed until the department heads and the Controller review and approve pre-payroll reports. Louise Biron will be responsible...

The City is transitioning to a new financial software program that will soon resolve this issue. An electronic approval level is being programmed so that payroll cannot be processed until the department heads and the Controller review and approve pre-payroll reports. Louise Biron will be responsible for this finding and the anticipated completion date is June 30, 2024.

View Audit 301192

Finding 390369 (2023-008)

Significant Deficiency 2023

City of Amsterdam, New York

NY

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

The City Engineer's Office has confirmed that they complete a timely debarment check for all lowest responsible bidders. They now document that a debarment check was made on their Recommendation to Award memo. This finding has been resolved.

View Audit 301192

Finding 390368 (2023-007)

Material Weakness 2023

City of Amsterdam, New York

NY

Reporting Internal Control / Segregation of Duties Cash Management

The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary p...

The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary parties. A draft SEFA worksheet will be created and updated on an ongoing basis throughout the fiscal year. This will improve the accuracy of internal federal award data. Louise Biron will be responsible for this finding and the anticipated completion date is June 30, 2024.

View Audit 301192

Finding 390308 (2023-004)

Material Weakness 2023

Wayne Community School District

IA

Internal Control / Segregation of Duties

COMMENT NUMBER: 2023-001 AND 2023-004 COMMENT TITLE: SEGREGATION OF DUTIES. CORRECTIVE ACTION PLAN: WE HAVE REVIEWED PROCEDURES AND PLAN TO MAKE THE NECESSARY CHANGES TO IMPROVE INTERNAL CONTROL. CONTACT PERSON, TITLE AND PHONE NUMBER: DENISE LARSON, BUSINESS MANAGER (641) 872-1284

View Audit 301177

Finding 390306 (2023-001)

Significant Deficiency 2023

University of Massachusetts Global-9 Month Audit

CA

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

University of Massachusetts Global concurs with this finding. To address this, a new control has been added beginning with the 2023-2024 fiscal year. The new step added is for a systems specialist to confirm that the batch process for award notifications has been completed, and that the notification...

University of Massachusetts Global concurs with this finding. To address this, a new control has been added beginning with the 2023-2024 fiscal year. The new step added is for a systems specialist to confirm that the batch process for award notifications has been completed, and that the notifications have been sent to students prior to disbursements of Title IV aid.

View Audit 301167

Finding 390305 (2023-002)

Significant Deficiency 2023

Memphis Housing Authority

TN

HUD Housing Programs Significant Deficiency Special Tests & Provisions

March 29, 2024 U.S. Department of Housing and Urban Development The Memphis Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2023. Berman Hopkins Wright & LaHam, CPAs and Associates, LLP 8035 Spyglass Hill Road Melbourne, FL 32940 Audit peri...

March 29, 2024 U.S. Department of Housing and Urban Development The Memphis Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2023. Berman Hopkins Wright & LaHam, CPAs and Associates, LLP 8035 Spyglass Hill Road Melbourne, FL 32940 Audit period: July 1, 2022 - 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. FINDINGS – FEDERAL AWARDS 2023-002 Special Tests and Provisions - Waiting List Public and Indian Housing Program - AL No. 14.850 Significant deficiency in internal control Other matter required to be reported in accordance with Uniform Guidance Condition: Out of 40 applicants that were selected from the waiting list for testing, 14 lacked documentation to show their current status and whether they were given the opportunity to be housed. In addition, there were difficulties obtaining any historical waiting lists for the Public Housing properties. Auditor’s Recommendations: The Authority should implement archiving procedures for its historical waiting lists on a routine basis. In addition, the Authority should document for proper auditing purposes, those given the opportunity to be housed from the waiting list and their current status. The Authority should provide proper training for all staff at the properties to ensure procedures and policies are being followed consistently across all of the Authority’s Public Housing properties. Action Taken: • MHA will ensure we have a saved copy of all public housing site-based waiting lists. LaTonia Young, Director of Asset Management, will save copies of the waiting list for all Public Housing sites on a monthly basis effective March 28, 2024. Tomecia Brown, Director of Compliance and Training will ensure that all site staff are trained on how to pull from the waiting list during the monthly site staff meeting effective April 23, 2024.

View Audit 301166

Finding 390304 (2023-001)

Significant Deficiency 2023

Memphis Housing Authority

TN

HUD Housing Programs Eligibility Significant Deficiency

2023-001 Eligibility Public and Indian Housing Program - AL No. 14.850 Significant deficiency in internal control Other matter required to be reported in accordance with Uniform Guidance Condition: Out of an approximate population of 2,083 tenants, 44 tenant files were tested and the following def...

2023-001 Eligibility Public and Indian Housing Program - AL No. 14.850 Significant deficiency in internal control Other matter required to be reported in accordance with Uniform Guidance Condition: Out of an approximate population of 2,083 tenants, 44 tenant files were tested and the following deficiencies were noted: • 1 file was missing the support packet for the fiscal year 2023 recertification including but not limited to income support, third party verification, and flat rent sheet, • 3 files had late recertifications, • 2 files were missing support of inspection, • 1 file was missing tenant wage support, and • 1 file was missing a valid 9886 form. Auditor Recommendations: The Authority should consider reevaluating their established procedures and controls in place to ensure full compliance in regards to eligibility. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: • 1 file was missing the support packet for the fiscal year 2023 recertification LaTonia Young, Director of Asset Management, lyoung@memphisha.org, 901-544-1129, is working with the new Community Manager to make the corrections for the missing information no later than April 30, 2024. Going forward Tomecia Brown, Director of Compliance and Training, tbrown1@memhisha.org, 901-544-6402, will continue to conduct file reviews to ensure that the required documentation is in the file. •3 files had late recertifications. We will ensure that all recertifications are completed within 30 – 120 days of the effective date. Tomecia Brown, Director of Compliance and Training, will complete a recertification due review on a monthly basis effective April 1, 2024. • 2 file was missing support of inspection. LaTonia Young, Director of Asset Management, will ensure that all units are inspected on an annual basis. In our monthly site staff meeting, Asset Management will inform staff to ensure that all inspections are in the file. • 1 file was missing tenant wage support. We will have the new Community Manager verify wages and make corrections by April 5, 2024. MHA will be sending the owner a non-compliance letter no later than April 30, 2024. Tomecia Brown, Director of Compliance and Training, will continue to complete file reviews on a monthly basis and train staff on the Public Housing process. • 1 file was missing a valid 9886 form. Tomecia Brown, Director of Compliance and Training, will continue to conduct file reviews to ensure that the HUD 9886 form is in the file for all Public Housing sites effective April 23, 2024.

View Audit 301166

Finding 390287 (2023-013)

Significant Deficiency 2023

Commonspirit Health

IL

Procurement, Suspension & Debarment Eligibility Reporting § 200.303

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Manageme...

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Management did not consistently retain evidence to support that internal controls were in place and operating effectively for approval of invoices with purchase orders and to ensure that bonuses paid to employees related to COVID-19 were eligible to receive the bonus. Corrective Action Plan: This program has ended. CHIC has no additional funding to apply expenses to.

View Audit 301158

Finding 390276 (2023-010)

Significant Deficiency 2023

Commonspirit Health

IL

Special Tests & Provisions Eligibility Reporting § 200.303

REFERENCE: 2023-010 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Tech...

REFERENCE: 2023-010 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science and CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Corrective Action Plan: This finding has been corrected for Good Samaritan as of April 2023. Enrollment reporting to the National Student Clearinghouse is conducted 5 times per year and reconciled monthly with loan borrowers to ensure active enrollment. Additional Status Update: The Dean of Enrollment Management validates and reports to the oversight committee regarding the monthly reporting. Monthly reporting to the GSC Compliance committee has verified completion since May 2023 and has been timely thereafter. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science David Velasquez, Nuclear Medicine Technologist Coordinator, CHI Health School of Radiologic Technology Expected Completion: April 2023 (Good Samaritan) and June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390274 (2023-008)

Significant Deficiency 2023

Commonspirit Health

IL

Special Tests & Provisions Student Financial Aid Eligibility § 200.303

REFERENCE: 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress SFA Cluster (Assistance Listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: CHI Health School of Radiologic Technology Finding: CHI Health School of Radiologic Technology had no docum...

REFERENCE: 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress SFA Cluster (Assistance Listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: CHI Health School of Radiologic Technology Finding: CHI Health School of Radiologic Technology had no documented evidence of review and approval of Satisfactory Academic Policy. Additionally, the Satisfactory Academic Policy did not contain all required elements according to federal regulations. Corrective Action Plan: CHI Health School of Radiologic Technology has revised the Satisfactory Academic Policy to incorporate the required components. Additionally, CHI Health will implement documentation procedures including an agenda and minutes for their annual meeting to review the school policies. Person Responsible: Robert Hughes, Program Director, CHI Health School of Radiologic Technology Expected Completion: June 2024

View Audit 301158

Corrective Action Plans

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