Corrective Action Plans

Finding 403902 (2022-002)

Material Weakness 2022

Aerospace MacHinists Joint Training Committee

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26...

Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26, 2023. All financial reporting policies and procedures will be reviewed and updated on an annual basis by AJAC Directors and Supervisors. Anticipated Completion Date: Completed

View Audit 310790

Finding 403889 (2022-003)

Significant Deficiency 2022

West Alabama Aids Outreach, Inc.

AL

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have institute...

Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have instituted multiple internal processes to confirm administrative fees do not exceed 10% of grant award. The grant biller will prepare a monthly reimbursement schedule in Excel which shows the budgeted amount for each category. The Director of Grants Management reviews and approves this schedule to ensure it meets the grant requirements. Each individual monthly reimbursement form is approved and signed by the Director of Grants Management to confirm accuracy. Then the reimbursement form submitted is entered in a master spreadsheet "Projects by Line Item" which shows original budget, monthly amounts billed for each budget line item, and remaining balance for each item. This is reviewed each month to ensure no amounts, including the administrative costs exceed approved amounts. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO

View Audit 310763 Questioned Costs: $1

Finding 403888 (2022-002)

Significant Deficiency 2022

West Alabama Aids Outreach, Inc.

AL

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.303

The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followe...

The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followed. For reimbursements, employees will complete an Employee Reimbursement Form which is signed by the employee and employee's direct supervisor. For purchase requests, employees will complete a Purchase Order form which is signed by the employee and the employee's supervisor. The signed form is sent to the finance department where it is entered in Bill.com for payment by accounts payable personnel. The Director of Finance approves the reimbursement or purchase on Bill.com, then the CFO approves and releases for payment. The approved Reimbursement Form or Purchase Order is sent to the Director of Grants Management, and if eligible, attached to the monthly billing to grantor for reimbursement. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO

View Audit 310763

Finding 403820 (2022-005)

Material Weakness 2022

Jft Recovery and Veterans Support Services

PA

Allowable Costs / Cost Principles Cash Management Material Weakness

As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fis...

As of 2023 we will be adding the following policy to the fiscal manual and to the operations manual to read as follows: All monthly program reports shall be completed by the coordinator and sent to the Deputy Director for approval, once approved they will be sent to the Fiscal Coordinator. The Fiscal Coordinator will then complete the billing amount and fiscal narrative then the report will be reviewed by the Deputy Director. Once approved the report will be presented to the Executive Director for final review, approval and signature and date placed on each report before it is sent to the funder. All program coordinators will complete a JFT outcomes report that is placed in an electronic reporting system and these reports will be reviewed quarterly by the Deputy Director. The Deputy Director does data analysis and these reports are placed in narrative form by the Deputy Director quarterly and the year-end report. These are shared with the funders according to the reporting requirements in the grant. All reports must be to funders by the 15th of the following month, unless otherwise stated in funder contract. The following policy will also be added to the fiscal manual: All budget modifications will be written up on the budget modification form and sent to the funder electronically once approved the form will be notated and include the funders signature, written on the form verbal communication from the funder, or a copy of the email with funder approval.

View Audit 310733

Finding 403816 (2022-001)

Material Weakness 2022

Jft Recovery and Veterans Support Services

PA

Internal Control / Segregation of Duties Material Weakness

In 2022 we were a small agency with minimal experience with federal and state grants. All our funding prior to this was private donations, fundraising and county funding. We grew very quickly in a short period of time. At the beginning of 2020, when we first received federal funding, we had six emp...

In 2022 we were a small agency with minimal experience with federal and state grants. All our funding prior to this was private donations, fundraising and county funding. We grew very quickly in a short period of time. At the beginning of 2020, when we first received federal funding, we had six employees and have since grown to over 40 employees. Since the time of the audit, we have gained knowledge and have already made changes to better meet the needs of our grant providers and our organization. With the segregation of duties, we started out with just one person handling the billing and the Executive Director overseeing all fiscal aspects. In the beginning of 2023, we have added two staff that work directly with the fiscal department to help with the segregation of duties and to have improved checks and balances in this department.

View Audit 310733

Finding 403613 (2022-001)

None 2022

Foundation for Puerto Rico, Inc.

PR

Reporting Internal Control / Segregation of Duties § 200.512

The Organization has established procedures to ensure that the Data Collection Form and Single Audit report are submitted within the established due date. Although the organization provided documentation in a complete and timely manner, unforeseen timing and resources issues, within the auditor fir...

The Organization has established procedures to ensure that the Data Collection Form and Single Audit report are submitted within the established due date. Although the organization provided documentation in a complete and timely manner, unforeseen timing and resources issues, within the auditor firm, did not allow us to perform and complete pending audit procedures and issue the report during the required period, in spite of exhausting all effort.

View Audit 310659

Finding 403501 (2022-001)

Significant Deficiency 2022

Firstmed Health and Wellness Center

NV

Reporting Internal Control / Segregation of Duties

The Center has established month end and annual reporting calendars with due dates. With significant turnover within executive and finance departments, this responsibility has been reassigned and monitored by the CFO.

View Audit 310590

Finding 403121 (2022-012)

Material Weakness 2022

State of California

CA

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

Public Health agrees that Form CMS-1539 should be signed. We are exploring reasons why so many forms were not signed, and we will work with our District office management to ensure that they are all signed going forward. Further, we will address this issue at our next meeting of District Managers, ...

Public Health agrees that Form CMS-1539 should be signed. We are exploring reasons why so many forms were not signed, and we will work with our District office management to ensure that they are all signed going forward. Further, we will address this issue at our next meeting of District Managers, District Administrators, and Health Facilities Evaluator Supervisors, and will work to update our training materials as necessary. Finally, we will also explore periodically pulling a sample of completed CMS-1539 forms to verify that signatures are present. Estimated Implementation Date: May 1, 2024 Contact: Elizabeth Moreno, Section Chief Business Operation Section Center for Health Care Quality, Office of Internal Operations California Department of Public Health

View Audit 310237

Finding 403119 (2022-010)

Material Weakness 2022

State of California

CA

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the exist...

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. Prior to this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life-saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, the Health Resources and Services Administration, which encouraged ADAP to reassess its organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help mitigate future findings in ADAP applications. Estimated Implementation Date: Implemented as of April 2022 Contact: Joseph Lagrama, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 310237

Finding 403118 (2022-009)

Material Weakness 2022

State of California

CA

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303

The Behavioral Health Administrative support team will endeavor to ensure that timesheets are collected and submitted appropriately. As the payroll system (SCO) and leave accounting (HRIS) are two completely separate programs that do not interact, the Behavioral Health (BH) Administrative Support T...

The Behavioral Health Administrative support team will endeavor to ensure that timesheets are collected and submitted appropriately. As the payroll system (SCO) and leave accounting (HRIS) are two completely separate programs that do not interact, the Behavioral Health (BH) Administrative Support Team will maintain a master file detailing the funding information for each position. For example, if a position is funded by two different grants, the file would reflect the percentage of work associated with each. It must be noted that as employee leave is tracked and maintained in a separate system, the Absence and Additional Time Worked Reports (STD 634) only reflect hours worked and leave used and does not reflect how a position is funded. Additionally, staff who are in Work Week Group E and are exempt from coverage under the Fair Labor Standards Act (FLSA) are not required to document hours worked for payroll purposes. Therefore, this form would only reflect leave credits used in whole-day increments. This means that on their timesheets, you will only find time used to cover full-day leave usage. These are generally our Supervisors and Managers. Estimated Implementation Date: July 2024 Contact: Raberta Gannon, Chief Behavioral Health Administrative Support Services Section Deputy Diretor’s Office, Behavioral Health California Department of Health Care Services

View Audit 310237

Finding 403116 (2022-008)

Material Weakness 2022

State of California

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of He...

The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of Health Care Services transitioned counties away from cost reconciliation financing, and for any state fiscal year after July 1, 2023, counties will no longer be required to submit cost reports. Estimated Implementation Date: July 2023 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 310237

Finding 403115 (2022-007)

Material Weakness 2022

State of California

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

California received $27 billion in State Fiscal Recovery Funds (SFRF) under the American Rescue Plan Act of 2021 to cover costs and mitigate the impacts of the COVID-19 pandemic. States that lost revenue due to the pandemic are permitted to use an amount of SFRF equivalent to their lost revenue, as ...

California received $27 billion in State Fiscal Recovery Funds (SFRF) under the American Rescue Plan Act of 2021 to cover costs and mitigate the impacts of the COVID-19 pandemic. States that lost revenue due to the pandemic are permitted to use an amount of SFRF equivalent to their lost revenue, as calculated pursuant to the U.S. Treasury’s Final Rule, to fund government services. The Department of Finance (Finance) acknowledges that its established review processes did not detect the inclusion of state employee contributions to deferred compensation plans in its revenue loss calculation and that these contributions did not constitute eligible revenue codes as they were not reported as revenues in the state’s basic financial statements. Due to unclear federal guidance, Finance’s original analysis and screening questions accounted for revenue codes that constituted revenues to the state from a budgetary perspective. Finance agrees that this oversight is a material weakness and has since adjusted its approach to the revenue loss calculation by excluding revenue codes that do not constitute revenues from a financial statement accounting perspective. However, Finance maintains that its overall controls and calculation process is sound and disagrees that this oversight was categorized as a material noncompliance finding. As stated in the finding, the overstated revenue loss amount did not impact expenditures reported for fiscal year 2022, and corrective action was taken before this finding and the state’s annual comprehensive financial report were released. The overstated revenue loss amount of $977,898,160 was not transferred from Fund 8506, which was established for the administration of the State Fiscal Recovery Funds received from the federal government, and was not used for the provision of government services. Estimated Implementation Date: January 2024 Contact: Mary Halterman, Assistant Program Budget Manager Federal Funds Cost Tracking & Accountability Unit California Department of Finance

View Audit 310237

Finding 403111 (2022-005)

Material Weakness 2022

State of California

CA

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condition...

Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board records in November 2020 to assist in verifying the income of PUA claimants who could not be automatically verified through these procedures. Such claimants were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California WBA of $167, and the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), on February 6, 2024, in accordance with the U.S. Department of Labor (DOL) Unemployment Insurance Program Letter 05-24, the California Employment Development Department (EDD) identified that the processing of PUA income documents and the SEES workloads must be considered resolved due to California’s finality laws. The EDD is prohibited by law from resolving these items by California Unemployment Insurance Code section 1376, which provides that EDD cannot establish overpayments more than one year after the close of the benefit year in which the overpayment was made unless the overpayment is found to be a result of fraud, misrepresentation, or willful nondisclosure. Given that there is no fraud or fault on the part of the individuals identified in these populations, EDD is unable to take the required actions to resolve the workload due to California’s finality law provisions. EDD is expecting a response from DOL agreeing with the application of California’s finality laws to the PUA income verification and the SEES workloads. Estimated Implementation Date: Upon DOL response, to be determined Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403109 (2022-004)

Material Weakness 2022

State of California

CA

Questioned Costs Eligibility Internal Control / Segregation of Duties § 200.303

As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency ...

As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency fraud task force that reviews fraud data and fraud reports on a continual basis and recommends adjustments to filters and tools as necessary. EDD has successfully halted two large fraud scheme attempts over the previous two years and continues to work towards immediate detection and prevention of fraud attempts. EDD will continue to analyze and assess our processes to stay ahead of the ever-evolving fraud landscape. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating PUA claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD has and will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: Annual reassessment to be completed September 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403094 (2022-003)

None 2022

The Pre-School Inc.

AR

Subrecipient Monitoring Internal Control / Segregation of Duties

If the Organization is subject to a Single Audit in the future, additional procedures will be implemented to track and monitor disbursements and allowable costs. Management does not anticipate having a Single Audit in the future.

View Audit 310234

Finding 401927 (2022-004)

Significant Deficiency 2022

The Wayside House, Inc. and Subsidiary

MN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

The Organization will implement control procedures that maintain proper segregation of duties. Federal program reporting shall be prepared by the Staff Accountant or program manager and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The p...

The Organization will implement control procedures that maintain proper segregation of duties. Federal program reporting shall be prepared by the Staff Accountant or program manager and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Staff Accountant, Andrea Vasquez, Chief Operating Officer, Alex Sukalski, New Controller, start date June 3, 2024. Anticipated Completion Date: May 2023

View Audit 309846

Finding 401926 (2022-003)

Significant Deficiency 2022

The Wayside House, Inc. and Subsidiary

MN

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being re...

The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access.

View Audit 309846

Finding 401741 (2022-002)

Material Weakness 2022

City of Hopkins

MN

Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN The following is our response to findings in the audit as of June 30, 2022 FINDING 2022-002 - Incomplete Schedule of Expenditures of Federal Awards During our audit, we discovered the City did not accurately prepare the Schedule of Expenditures of Federal Awards to include all...

CORRECTIVE ACTION PLAN The following is our response to findings in the audit as of June 30, 2022 FINDING 2022-002 - Incomplete Schedule of Expenditures of Federal Awards During our audit, we discovered the City did not accurately prepare the Schedule of Expenditures of Federal Awards to include all federal awards.. Corrective Action Plan (CAP): 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The City will establish procedures to ensure future schedule of expenditures of federal awards includes all federalexpenditures. 3.Official Responsible for Ensuring CAP: Nick Bishop, Business Manager, is the official responsible for ensuring corrective action. 3. Planned Completion Date for CAP: Fiscal year end 2023. 4. Plan to Monitor Completion of CAP: The City Council will be monitoring this corrective action plan. Sincerely, Nick Bishop City Finance Director

View Audit 309670

Finding 401686 (2021-001)

Material Weakness 2022

Municipality of Gregory

SD

Internal Control / Segregation of Duties Material Weakness

The City of Gregory Finance Officer, Trudy Waterman, with the Mayor, Al Cerny, are the contact persons responsible for the corrective action plan for this finding. Finding Number 2021-001 is due to the limited number of staff the City of Gregory can afford to have on the payroll budget. The Mayor,...

The City of Gregory Finance Officer, Trudy Waterman, with the Mayor, Al Cerny, are the contact persons responsible for the corrective action plan for this finding. Finding Number 2021-001 is due to the limited number of staff the City of Gregory can afford to have on the payroll budget. The Mayor, City Council Members, and Finance Administration employees are aware of the risk and have taken steps to reduce that risk. Our Assistant Finance Officer is solely in control of generating utility bills, the Finance Officer helps collect and oversee the collection of revenues through the current municipal software in the Receipts Management Module and Front Desk. The Finance Officer also conducts reconciliation on all accounts and would be required to report any discrepancies to the Mayor and Council. Our Finance Administration is required to run all revenue and expense reports monthly, our check signing procedures require two signatures, most generally the Mayor and one of the two employees in the Finance Administration. The Assistant Finance Officer and Finance Officer jointly conduct the payroll process and jointly fill out the claim couchers and the claims list is presented to the City Council at each meeting.

View Audit 309637

Finding 401579 (2022-008)

Significant Deficiency 2022

Martin University

IN

Questioned Costs Eligibility Significant Deficiency § 200.303

2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. E...

2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal financial reporting process. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 309593 Questioned Costs: $1

Finding 401563 (2022-009)

Material Weakness 2022

Martin University

IN

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring § 200.303

2022-009 Special Tests and Provisions – The Gramm-Leach-Bliley Act (GLBA) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leac...

2022-009 Special Tests and Provisions – The Gramm-Leach-Bliley Act (GLBA) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leach-Bliley Act that have not been completed and documented and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University began engagement with AIS, an IT Managed Service Provider in May 2022 and hired a Director of IT in November 2023. The University is working with AIS and Cowbell to develop and implement a Cybersecurity policy, as well as to provide training for all employees, the Board of Governors, and students. The University has also deployed Cloud Storage backup solutions for all data. Name(s) of the contact person(s) responsible for corrective action: Scharvin Wilson, Director of IT, AIS, IT Managed Services Provider, E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401561 (2022-006)

Significant Deficiency 2022

Martin University

IN

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring § 200.303

2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the docu...

2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented policy and procedures that require a review of all official and unofficial withdrawals to have R2T4 calculations on a real time basis to ensure compliance with the Department of Education guidelines on a consistent and regular basis. Internal audits of the process will also be implemented for continuous improvement. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401559 (2022-004)

Significant Deficiency 2022

Martin University

IN

Questioned Costs Student Financial Aid Significant Deficiency § 200.303

2022-004 Special Tests and Provisions – Outstanding Checks over 240 Days Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the University review its procedures related to outstanding student refund checks to ensure they are being ...

2022-004 Special Tests and Provisions – Outstanding Checks over 240 Days Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the University review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal financial reporting process. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 309593 Questioned Costs: $1

Finding 401558 (2022-003)

Significant Deficiency 2022

Martin University

IN

Internal Control / Segregation of Duties Student Financial Aid Reporting § 200.303

2022-003 Reporting – FISAP Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the applicable campus revise procedures to ensure that the record retention requirements are met and supporting documentation agrees to the FISAP, including a...

2022-003 Reporting – FISAP Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the applicable campus revise procedures to ensure that the record retention requirements are met and supporting documentation agrees to the FISAP, including a supervisory review by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal and external financial reporting process. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401557 (2022-002)

Material Weakness 2022

Martin University

IN

Internal Control / Segregation of Duties Material Weakness Reporting

2022-002 Segregation of Duties Recommendation: The University should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including number of internal staff), to determine whether additional processes and controls over the financial...

2022-002 Segregation of Duties Recommendation: The University should evaluate their financial reporting processes and controls, including the segregation of duties among its internal staff (including number of internal staff), to determine whether additional processes and controls over the financial records of the University are complete, accurate, and retained to support the University’s financial statement prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University has begun to restructure all accounting and reconciliation functions, including implementation of new accounting software. The University is implementing financial internal controls to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Corrective Action Plans

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