Corrective Action Plans

Finding 369663 (2023-001)

Material Weakness 2023

Mountain Community Health Partnership, Inc.

NC

Special Tests & Provisions Internal Control / Segregation of Duties

In Finding 2023-001, it was reported that the Organization did not properly apply the sliding fee discount for three sliding fee patients tested. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2023-001, proper training will be given to employe...

In Finding 2023-001, it was reported that the Organization did not properly apply the sliding fee discount for three sliding fee patients tested. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2023-001, proper training will be given to employees and sliding fee applications and discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.

View Audit 291050

Finding 369632 (2023-001)

Significant Deficiency 2023

Wayside House, Inc.

FL

Reporting Internal Control / Segregation of Duties

Management Response: The Organization will continue to strengthen our internal controls by having the employees complete the required Time and Effort certifications monthly or semiannually with further review and approval by the respective Department Heads. The employees will certify their monthly p...

Management Response: The Organization will continue to strengthen our internal controls by having the employees complete the required Time and Effort certifications monthly or semiannually with further review and approval by the respective Department Heads. The employees will certify their monthly personnel activity reports indicating actual time spent working on multiple activities or cost objectives, while employees who worked on a single cost objective will submit semi‐annual Time and Effort certifications reviewed and approved by their Department Heads.

View Audit 291011

Finding 369629 (2023-002)

Significant Deficiency 2023

Drexel Foundation for Educational Excellence, Inc.

IN

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.326

INDING 2023-002 – DAVIS-BACON COMPLIANCE – Significant Deficiency Planned corrective action: The School through the education services provider agreement with Entrepreneurial Ventures in Education (EVE) will train operations and business office staff on thecompliance requirements under Davis-Bacon t...

INDING 2023-002 – DAVIS-BACON COMPLIANCE – Significant Deficiency Planned corrective action: The School through the education services provider agreement with Entrepreneurial Ventures in Education (EVE) will train operations and business office staff on thecompliance requirements under Davis-Bacon to ensure construction contracts are entered into with qualified contractors and obtain and retain appropriate certified payroll documenta􀆟on during the construction period. Responsible officers: Carlo Hershberger, Director of Finance and Accounting; Javier Dimas, Vice- President of Operations; Martha Arellano, Procurement Manager and Buyer Estimated completion date: March 15, 2024

View Audit 291003

Finding 369627 (2023-001)

Significant Deficiency 2023

Drexel Foundation for Educational Excellence, Inc.

IN

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency § 200.334

FINDING 2023-001 – DOCUMENT RETENTION – Significant Deficiency Planned correcive action: The School through the educational service provider agreement with Entrepreneurial Ventures in Education (EVE) will provide additional training to school staff that are responsible for maintaining records that i...

FINDING 2023-001 – DOCUMENT RETENTION – Significant Deficiency Planned correcive action: The School through the educational service provider agreement with Entrepreneurial Ventures in Education (EVE) will provide additional training to school staff that are responsible for maintaining records that identify the poverty levels of students enrolled. Additionally, EVE shall conduct an internal audit to ensure that documents are being collected and stored appropriately. Responsible officers: Lili Cruz-Gilbes, Regional Director of Compliance and State Reporting Estimated completion date: March 15, 2024

View Audit 291003

Finding 369626 (2023-003)

None 2023

St. Thomas University Inc.

FL

Special Tests & Provisions Procurement, Suspension & Debarment Student Financial Aid

The Business Office has implemented measures to ensure that Perkins Promissory Notes are identified, stored, and accessible during their repayment and collection period. In addition to the current filing system, the Business Office will utilize management software for ease of access and recording. ...

The Business Office has implemented measures to ensure that Perkins Promissory Notes are identified, stored, and accessible during their repayment and collection period. In addition to the current filing system, the Business Office will utilize management software for ease of access and recording. To ensure that all remaining promissory notes are kept in accordance with Department of Education regulations, the Business Office will: • Record all incoming promissory notes internally and externally. • Promissory notes created prior to 2013 will be made digitally accessible through Perceptive Content, a secure content management system. Access to these promissory notes will only be accessible by parties with authorized access. • Promissory notes created after 2013 will continue to be made available through Heartland ECSI’s third party filing system. ECSI records paid, completed, cancelled, and retired promissory notes that were created after 2013. • In accordance with the Perkins Assignment and Liquidation Guide from the Department of Education (EA ID: General-21-53), all accounts with promissory notes unable to be located will be written off and/or purchased from the Department of Education. The Policy and Procedures manual has been updated to reflect this process. Contact Person: Maribel Smith, Controller

View Audit 291002

Finding 369625 (2023-002)

None 2023

St. Thomas University Inc.

FL

Special Tests & Provisions Student Financial Aid Internal Control / Segregation of Duties

In June 2023, St. Thomas University transitioned to Paycom, a cloud-based payroll service that offers payroll processing and HR services in a single software, STU utilizes the Time and Attendance module for students Timesheets. All timesheets are electronically saved, in the event an Employee submi...

In June 2023, St. Thomas University transitioned to Paycom, a cloud-based payroll service that offers payroll processing and HR services in a single software, STU utilizes the Time and Attendance module for students Timesheets. All timesheets are electronically saved, in the event an Employee submits a paper time sheet due to a missed time period, the document is scanned and saved in the shared payroll file. Training is being provided for students and supervisors to reduce the need for any paper timesheets. The Policy and Procedures manual has been updated to reflect this process. Contact Person: Neville Bates, Payroll Manager

View Audit 291002

Finding 369619 (2023-001)

None 2023

St. Thomas University Inc.

FL

Special Tests & Provisions Internal Control / Segregation of Duties

The Office of information Technology completed an IT Audit and Penetration Test. Results have been received and OIT and the Office of Communications is planning to complete all recommendations accordingly. This includes: 1. Website vulnerabilities cleanup. (Communications Team) a. Complete by May 1,...

The Office of information Technology completed an IT Audit and Penetration Test. Results have been received and OIT and the Office of Communications is planning to complete all recommendations accordingly. This includes: 1. Website vulnerabilities cleanup. (Communications Team) a. Complete by May 1, 2024 2. Server Patching where applicable (OIT) a. Complete by May 1, 2024 3. Complete recommendations presented by the auditor (OIT and a third party contractor, Forsyte) a. Complete by July 1, 2024 Contact Person: John Honchell, OIT

View Audit 291002

Finding 369618 (2023-001)

Material Weakness 2023

Nutrition Plus Inc.

KS

Internal Control / Segregation of Duties

We will continue to have the Board of Directors review the financial activity of the entity. Due to the small size of the organization, it is not economically feasible to achieve a complete segregation of duties.

View Audit 291001

Finding 369604 (2023-006)

Significant Deficiency 2023

Arizona Christian University

AZ

Student Financial Aid Eligibility Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review its procedures related to firsttime borrowers to ensure they are in compliance with the Department of Education's regulations. Explanation of disagreement with audit finding:...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review its procedures related to firsttime borrowers to ensure they are in compliance with the Department of Education's regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We hold all first-time freshman loan funds for 30 days after the start to ensure we are not paying anyone early. Additionally, we will run an entrance term report prior to the start of the semester/term. From this report we can identify all first-time borrowers and tag them in populi. Prior to batching federal funds, the financial aid office will pull a report by said tag and ensure disbursements dates are 30 days from the start of the term/semester. Name(s) of the contact person(s) responsible for corrective action: Lisa Stone, Joyce Hatch and Kelly Reyes Planned completion date for corrective action plan: November 2023

View Audit 290967

Finding 369599 (2023-005)

Significant Deficiency 2023

Arizona Christian University

AZ

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various 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 ...

Student Financial Assistance Cluster – Assistance Listing No. Various 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: We have created a Stale check policy & procedure. The financial aid department will work in concert with student accounts and accounts payable to ensure compliance. The process has checkpoints starting at 30, 60 up to 180 days. 60 days before a check reaches 240 days. Name(s) of the contact person(s) responsible for corrective action: Lisa Stone, Joyce Hatch, Kelly Reyes, Michael Warner, Christy Krahn and Vikki Straw. Planned completion date for corrective action plan: November 2023

View Audit 290967 Questioned Costs: $1

Finding 369594 (2023-004)

Significant Deficiency 2023

Arizona Christian University

AZ

Questioned Costs Eligibility Significant Deficiency

tudent Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University implements policies to review all student award packages at the start of the academic year to ensure no over awards exist. Explanation of disagreement with audit finding: There is no disa...

tudent Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University implements policies to review all student award packages at the start of the academic year to ensure no over awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Department will review all student award packages at the midpoint of each semester to ensure no overawards exist. Name(s) of the contact person(s) responsible for corrective action: Lisa Stone, Joyce Hatch, and Kelly Reyes Planned completion date for corrective action plan: May 2024

View Audit 290967 Questioned Costs: $1

Finding 369589 (2023-003)

Significant Deficiency 2023

Arizona Christian University

AZ

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Institute review its reporting procedures to ensure that students’ statuses are timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disa...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Institute review its reporting procedures to ensure that students’ statuses are timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: After an analysis of the auditor's finding, ACU's director of financial aid, AVP of institutional effectiveness, and associate director of institutional research concluded that a misunderstanding of the National Clearinghouse's process for summer enrollment reporting was the cause of the finding. During the summer months of June, July, and August, ACU has been submitting enrollment reports, including withdrawals, only for students enrolled in summer terms. Withdrawals of students enrolled in the spring term were not being reported until after the fall term commenced. To remedy this finding, the Department of Financial Aid (FA) and the Office of Institutional Effectiveness (OIE) has coordinated with the National Student Clearinghouse (NSC) to identify which reporting method would ensure that all withdrawn students are accounted for and reported between the spring and fall terms. It was determined we would send custom files that include all withdrawn students in early June and July. The report will be uploaded through the NSC's secure file upload system at least once between May 30th and August 30th, with no more than 60 days between any two enrollment file submissions. Name(s) of the contact person(s) responsible for corrective action: Lisa Stone, Jeff Phillips and Eric Tompkins Planned completion date for corrective action plan: May/June 2024

View Audit 290967

Finding 369584 (2023-002)

Significant Deficiency 2023

Arizona Christian University

AZ

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit fi...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The incorrect date was for a student who received the Pell Grant. When we batch Pell student awards in COD; and return funds at the same time, this will often cause a shortage in our Pell G5 account. This will delay the disbursement date on the school side. Although COD releases the disbursement, the funds are not available in G5 until days later and in some cases weeks later. The first step is to not process returns and draw downs at the same time. This will ensure the funds are in the Pell G5 acount so disbursment dates will match. The second piece is to audit the disbursement dates at the end of each semester to ensure we match. Name(s) of the contact person(s) responsible for corrective action: Lisa Stone, Joyce Hatch and Kelly Reyes Planned completion date for corrective action plan: November 2023

View Audit 290967

Finding 369583 (2023-004)

Significant Deficiency 2023

Domestic Violence Crisis Center

ND

Cash Management Internal Control / Segregation of Duties

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc. will review their process for allocating expenses to ensure the proper time is being charged to the correct time period. Completion Date: The Center completed this review in July 2023.

View Audit 290966

Finding 369581 (2023-001)

Significant Deficiency 2023

City of Columbia, Missouri

MO

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Department of Public Health and Human Services (PHHS) will create the proper processes and procedures to track reporting requirement and document internal review and approvals prior to report submissions. The Grant Administrator will create the proper processes and procedures to track reporting ...

The Department of Public Health and Human Services (PHHS) will create the proper processes and procedures to track reporting requirement and document internal review and approvals prior to report submissions. The Grant Administrator will create the proper processes and procedures to track reporting requirements and notify departments of upcoming submission deadlines.

View Audit 290965

Finding 369576 (2023-003)

Significant Deficiency 2023

Arc Knox County

TN

Reporting Internal Control / Segregation of Duties

Accounting responsibilities between accounting staff are being evaluated and will be reassigned to include bank reconciliation responsibilities and any accounting functions regarding recording & reporting of federal awards. All changes in accounting responsibilities will be reassigned and implemente...

Accounting responsibilities between accounting staff are being evaluated and will be reassigned to include bank reconciliation responsibilities and any accounting functions regarding recording & reporting of federal awards. All changes in accounting responsibilities will be reassigned and implemented by the end of fiscal year 2023-2024.

View Audit 290951

Finding 369513 (2023-003)

Material Weakness 2023

Rapid City Club for Boys, Inc.

SD

Internal Control / Segregation of Duties Subrecipient Monitoring

Finding No 2023-003: Heartland Heights Apartments Responsible Individuals: Roni Williamson, Controller Corrective Action Plan: The Organization has met with Lloyd Property Management and has been receiving regular financial statements. The Organization will implement a plan to evaluate internal cont...

Finding No 2023-003: Heartland Heights Apartments Responsible Individuals: Roni Williamson, Controller Corrective Action Plan: The Organization has met with Lloyd Property Management and has been receiving regular financial statements. The Organization will implement a plan to evaluate internal controls to ensure adequacy and effectiveness. Anticipated Completion Date: Ongoing

View Audit 290783

Finding 369496 (2023-002)

Significant Deficiency 2023

McKenzie Housing Authority

TN

HUD Housing Programs Internal Control / Segregation of Duties

Finding 2023-002 Waiting List for Public Housing: Corrective Action Plan: Beginning February 2024, the waiting list will be printed monthly by staff and retained for a two year period.

View Audit 290769

Finding 369493 (2023-001)

Material Weakness 2023

Mineral Point Unified School District

WI

Internal Control / Segregation of Duties

Finding #2023-001 - Limited Segregation of Duties (Prior Year Finding #2022-001) Condition:The available office staff precludes a proper segregation of duties in the following control areas: payroll, cash receipts, and cash disbursements. Effect:Because of the lack of segregation of duties, errors o...

Finding #2023-001 - Limited Segregation of Duties (Prior Year Finding #2022-001) Condition:The available office staff precludes a proper segregation of duties in the following control areas: payroll, cash receipts, and cash disbursements. Effect:Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Cause: Due to the small size of the District there is only one person in the bookkeeping department, who records all transactions and performs reconciliations. Criteria: Checks and balances should be in place to allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct any misstatements on a timely basis. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the District's operations. Response:We agree with this finding but due to the size of our District and financial constraints do not believe it is cost effective to increase the office staff in an attempt to bring about a more effective segregation of duties. The Board of Education and Administration personnel review monthly treasurer reports, and approve disbursements monthly. Any concerns or questions are addressed throughout the year. Management will review various accounting functions periodically.

View Audit 290755

Finding 369455 (2023-001)

Significant Deficiency 2023

Clinton Township Housing Commission

MI

Questioned Costs Procurement, Suspension & Debarment Eligibility

The Clinton Township Housing Commission Board has been reeducated, by our Fee accountant about the proper use of HUD Funding. The CTHC board understands that HUD funds CANNOT be used in to provide any type of Bonuses to staff and or any of its affiliates. All Commissioners will attend Commissioner’s...

The Clinton Township Housing Commission Board has been reeducated, by our Fee accountant about the proper use of HUD Funding. The CTHC board understands that HUD funds CANNOT be used in to provide any type of Bonuses to staff and or any of its affiliates. All Commissioners will attend Commissioner’s training to insure proper education on their roles and expectations.

View Audit 290651 Questioned Costs: $1

Finding 369446 (2023-001)

Material Weakness 2023

Lapeer Community Schools of Lapeer County

MI

Internal Control / Segregation of Duties Material Weakness Reporting

Condition: Final Expenditure Reports due on November 29, 2022 for the ESSER II Section 23b Credit Recovery grant and the ESSER II Section 23b Before/After School grant were submitted on September 11, 2023. Planned Corrective Action: Finding has been corrected. Upon discovery of the oversight, the Fi...

Condition: Final Expenditure Reports due on November 29, 2022 for the ESSER II Section 23b Credit Recovery grant and the ESSER II Section 23b Before/After School grant were submitted on September 11, 2023. Planned Corrective Action: Finding has been corrected. Upon discovery of the oversight, the Final Expenditure Reports were reopened and completed on September 11, 2023. Further, the District acknowledges the lack of timeliness of submitting the Final Expenditure Reports, and has implemented procedures to ensure all reporting surrounding final expenditures is completed and submitted to granting authority in accordance with terms of the agreement going forward. Contact person responsible for corrective action: Erica Ingles, Finance Director and Jennifer Mudge, Supervisor of School Improvement and Grant Programs Anticipated Completion Date: 9/11/2023

View Audit 290639

Finding 369439 (2023-002)

Material Weakness 2023

Women of Nations

MN

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.430

2023-002 Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: WON should implement a process to complete time and effort certifications and reconcile those certifications to ensure the costs reported to the grantor are accurate. All additional amounts paid contain documentation th...

2023-002 Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: WON should implement a process to complete time and effort certifications and reconcile those certifications to ensure the costs reported to the grantor are accurate. All additional amounts paid contain documentation that they are properly authorized. All employees should have timesheets to support the hours worked and charged to the grant. These timesheets should be formally approved by a supervisor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Women of Nations has updated its payroll policies and procedures to ensure that time and effort certifications are completed correctly and approved in a timely manner by supervisors. Name(s) of the contact person(s) responsible for corrective action: Charles Nelson Planned completion date for corrective action plan: June 1, 2023

View Audit 290620 Questioned Costs: $1

Finding 369429 (2023-005)

None 2023

Newberry College

SC

Questioned Costs Student Financial Aid Internal Control / Segregation of Duties

Incorrect Pell Calculations Planned Corrective Action: The process for awarding and disbursing summer Pell Grants is being discussed. The new process will involve a thorough review of summer enrollment. Aid will disburse for session 1 and session 2 after the last day to add or drop a course. The ...

Incorrect Pell Calculations Planned Corrective Action: The process for awarding and disbursing summer Pell Grants is being discussed. The new process will involve a thorough review of summer enrollment. Aid will disburse for session 1 and session 2 after the last day to add or drop a course. The director will oversee summer awarding and the senior associate director will assist by providing necessary reports. Person Responsible for Corrective Action Plan: Karen Benfield, Director of Financial Aid Anticipated Date of Completion: This process will be finalized by June 2024.

View Audit 290607 Questioned Costs: $1

Finding 369428 (2023-004)

Significant Deficiency 2023

Newberry College

SC

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

USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: Reserve accounts to be funded per USDA requirements. Person Responsible for Corrective Action Plan: Jon Kokos, CFO Anticipated Date of Completion: June 30, 2024

View Audit 290607

Finding 369371 (2023-005)

Significant Deficiency 2023

Oklahoma Panhandle State University

OK

Questioned Costs Student Financial Aid Significant Deficiency § 200.303

Federal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend the Universi...

Federal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend the University document review of Return to Title IV calculations by an employee that did not prepare the calculations. We also recommend that the University review policies and procedures related to R2T4 calculations to ensure calculations are performed correctly and disbursed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial aid personnel will implement Return to Title IV FSA calculation spreadsheet for additional backup support in determining if banner has calculated return amounts correctly. Additionally, financial aid will require all R2T4 calculations to be secondarily reviewed and confirmed in RHACOMM. The scheduled breaks for each semester will be determined by the Director of Financial Aid and given to the Registrar to be input into banner module SOATBRK. These breaks are what banner then uses for Return to Title IV purposes. Update procedures to reflect additional actions. Name(s) of the contact person(s) responsible for corrective action: Dasha Smith Planned completion date for corrective action plan: 4/1/24

View Audit 290586 Questioned Costs: $1

Corrective Action Plans

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