Corrective Action Plans

Finding 384785 (2023-001)

Significant Deficiency 2023

NE

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

The College identified what took place during contact with the Clearinghouse. Student records have been updated and procedures have been implemented to ensure accuracy of enrollment reporting in addition to implementing review procedures between college records and NSLDS enrollment reports.

View Audit 297900

Finding 384766 (2023-003)

Material Weakness 2023

Housing Authority of the City of Martinsburg

WV

Questioned Costs Eligibility Procurement, Suspension & Debarment

Finding 2023-003 - Documentation of Costs and Vendor Invoices - Financial Reporting and Internal Controls ALN 14.850 & 14.871- Noncompliance & Material Weakness Corrective Action Plan: Vendor invoice backup supplied to HUD for questionable expense s. Executive Director must approve all expenses goi...

Finding 2023-003 - Documentation of Costs and Vendor Invoices - Financial Reporting and Internal Controls ALN 14.850 & 14.871- Noncompliance & Material Weakness Corrective Action Plan: Vendor invoice backup supplied to HUD for questionable expense s. Executive Director must approve all expenses going forward and keep sufficient backup for audit. Person Responsible: John Sales, Interim Executive Director Anticipated Completion Date: January 31, 2024

View Audit 297881 Questioned Costs: $1

Finding 384765 (2023-002)

Material Weakness 2023

Housing Authority of the City of Martinsburg

WV

Cash Management HUD Housing Programs Material Weakness

Finding 2023-002 -Accounting Controls - Cash Management & Program Compliance ALN 14.850 - Grant years 2022, 2023 - Noncompliance & Material Weakness Corrective Action Plan: Accounting computer automation and hiring of experienced Executive Director and a Finance staff person who can follow HUD guid...

Finding 2023-002 -Accounting Controls - Cash Management & Program Compliance ALN 14.850 - Grant years 2022, 2023 - Noncompliance & Material Weakness Corrective Action Plan: Accounting computer automation and hiring of experienced Executive Director and a Finance staff person who can follow HUD guidelines and compliance should correct controls and record keeplng for the future. Person Responsible: John Sales, Interim Executive Director Anticipated completion Date: March 31,2024

View Audit 297881

Finding 384759 (2023-001)

Significant Deficiency 2023

Milwaukee School of Engineering

WI

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

Condition: The University did not have documented controls in place, reviewing that the comprehensive information security program was in compliance with the Safeguards Rule and was prepared and in place by June 9, 2023 Corrective Action Planned:The University will reevaluate procedures to ensure t...

Condition: The University did not have documented controls in place, reviewing that the comprehensive information security program was in compliance with the Safeguards Rule and was prepared and in place by June 9, 2023 Corrective Action Planned:The University will reevaluate procedures to ensure that all reports required under Uniform Guidance are reviewed, approved, documented, and retained in a timely manner. Name(s) of Contact Person(s) Responsible for Corrective Action: Richard Thomas, Senior Director of IT Informational Technology, and Paul Matson, CFO & VP of Finance

View Audit 297875

Finding 384754 (2023-014)

Significant Deficiency 2023

State of Kansas

KS

Matching / Level of Effort / Earmarking § 200.303

Condition: From a sample of sixty providers, nine of the providers did not have a recertification survey completed within the required timeframe which is used to meet the provider health and safety standards. Recommendation: We recommend the State train all staff members to properly verify provide...

Condition: From a sample of sixty providers, nine of the providers did not have a recertification survey completed within the required timeframe which is used to meet the provider health and safety standards. Recommendation: We recommend the State train all staff members to properly verify providers are meeting the prescribed health and safety standards before making payments to those providers. Views of responsible officials: KDHE/Bureau of Facilities and Licensing (BFL) recognizes the recertification survey deadlines was not met for nine of the sixty non-deemed acute and continuing care providers and supplier types included in this audit consisting of Hospitals, Critical Access Hospitals (CAH), Ambulatory Surgery Centers (ASC), End Stage Renal Disease Facilities (ESRD), Rural Health Clinics (RHC), Hospice and or Home Health Agencies (HHA). The KDHE/BFL would like to clarify that Section 1865(a)(1) of the Social Security Act (the Act) permits providers and suppliers "accredited" or "deemed" by an approved national accreditation organization (AO) to be exempt from routine surveys by State survey agencies to determine compliance with Medicare conditions. Accreditation by an AO is voluntary and is not required for Medicare certification or participation in the Medicare Program.) There is no disagreement with the audit finding but KDHE/BFL does want to identify some of the challenges the State Survey Agency (SSA) faces hindering continued progress with corrective action plans. CMS’s annual appropriation to the SSA has remained unchanged since FY 2015. This has significantly limited the SSA’s capacity to conduct initial, complaint, recertification, and validation surveys. This limitation in funding, coupled with the continuing effects of the COVID-19 Public Health Emergency (PHE), accelerated the loss of SSA surveyor resources and resulted in an ongoing survey backlog. As complaints about provider and supplier quality of care increases, non-statutory recertification surveys and less severe complaint allegations receive a lower priority. Complaint surveys, especially those alleging immediate jeopardy or actual harm to patient health and safety are the primary oversight provided, outside of statutory recertification surveys. These investigations of the most serious allegations also lead to more severe findings, higher numbers of revisits, and additional enforcement workload. Complaint surveys are the primary oversight mechanism for most provider types. CMS has established the following priorities for the SSA’s: 1. Investigation of patient complaints, as these are active quality concerns that must be reviewed to protect the health and safety of the public. 2. Survey and recertification of statutory facilities such as home health agencies (HHAs), and hospices as required by current law; and 3. Survey and recertification of non-statutory facilities, as required by CMS policy with consideration of available funding once priorities one and two have been accomplished. Action taken in response to finding: At the beginning of each federal fiscal year including current FFY24, the BFL utilizes the CMS Mission and Priority Document (MPD) which directs and outlines the work of the SA based on regulatory changes, adjustments in budget allocations, and new initiatives, as well as new requirements based on statutes to prioritize and categorize survey plans. During this current FFY we have begun to restructure the program adding additional program manager positions, health facility surveyors, contracted services, and other support staff. Our goal is always to be able to consistently meet our Tier 1 priority with an emphasis on Tier 2. Recruitment, training, fiscal management & strategies are always a priority and part of action plans to meet these goals. The SSA goals for FFY24: • Complete 100% of the ESRD surveys in Tier 2 provided on the required Outcomes List. Kansas currently has approximately 60 non-deemed ESRD suppliers. • Complete to the extent possible 5% of non-deemed RHCs based on state judgment prioritizing those RHCs most at risk of quality problems for Tier 2. Kansas currently has approximately 135 RHC suppliers. • Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey with a maximum interval between surveys for any one particular HHA of 36.9 months to meet Tier 1 requirements. Kansas currently has approximately 70 non-deemed, certified HHA’s. • Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey with a maximum interval between surveys for any one particular Hospice of 36 months to meet Tier 1 requirements. Kansas currently has approximately 50 non-deemed, certified Hospice providers • Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey at least one, but not less than 5% of the non-deemed hospitals, 5% of the non-deemed psychiatric hospitals, and 5% of non-deemed CAHs. Kansas currently has approximately 74 non-deemed CAHs, 2 Psychiatric/Rehab non-deemed hospitals and 12 non-deemed hospitals. Name(s) of the contact person(s) responsible for corrective action: Jerry Smith, Bureau Director, Bureau of Facilities and Licensing, KDHE, Gerald.Smith@ks.gov Marilyn St Peter, RN, Deputy Director, Bureau of Facilities and Licensing, KDHE, Marilyn.St.Peter@ks.gov Planned completion date for corrective action plan: June 30, 2024

View Audit 297874

Finding 384749 (2023-010)

Significant Deficiency 2023

State of Kansas

KS

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Condition: During testing, we noted that FFATA reports were not submitted timely and there was not a documented review of the submitted reports. Also, we noted that the State also has submitted FFATA Reports to FSRS for vendors when this reporting is not required for vendors. Transactions Tested Su...

Condition: During testing, we noted that FFATA reports were not submitted timely and there was not a documented review of the submitted reports. Also, we noted that the State also has submitted FFATA Reports to FSRS for vendors when this reporting is not required for vendors. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements 6 0 6 0 0 Dollar Amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $2,291,464 $0 $2,291,464 0 0 Recommendation: We recommend that the agency implement controls to ensure reports are reviewed before submission, that a process is updated to ensure that reports are submitted timely, and that a process is implemented to ensure only subawards are reported to FSRS. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The agency has put a review/approval workflow process in place for reports. The report will be entered into FSRS.gov and sent to a reviewer. Once the report has been reviewed and approved, an email will be sent to Fiscal Analyst as proof the reports have been reviewed/approved. The email will be retained for audit reviews. Name(s) of the contact person(s) responsible for corrective action: Joy Duncan Planned completion date for corrective action plan: The review process will begin immediately in March 2024.

View Audit 297874

Finding 384747 (2023-009)

Significant Deficiency 2023

State of Kansas

KS

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Condition: During testing it was discovered that management did not document the review of the submitted reports. Also, we noted that the State also has submitted FFATA Reports to FSRS for vendors when this reporting is not required for vendors. Transactions Tested Subaward Not Reported Report Not T...

Condition: During testing it was discovered that management did not document the review of the submitted reports. Also, we noted that the State also has submitted FFATA Reports to FSRS for vendors when this reporting is not required for vendors. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements 1 0 0 0 0 Dollar Amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $41,680 0 0 0 0 Recommendation: We recommend that the agency implement controls to ensure reports are reviewed before submission and that a process is implemented to ensure only subawards are reported to FSRS. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The agency has put a review/approval workflow process in place for reports. The report will be entered into FSRS.gov and sent to a reviewer. Once the report has been reviewed and approved, an email will be sent to Fiscal Analyst as proof the reports have been reviewed/approved. The email will be retained for audit reviews. Name(s) of the contact person(s) responsible for corrective action: Joy Duncan Planned completion date for corrective action plan: The review process will begin immediately in March 2024.

View Audit 297874

Finding 384741 (2023-006)

Significant Deficiency 2023

State of Kansas

KS

Matching / Level of Effort / Earmarking Reporting § 200.303

Condition: During our testing of performance reports, we noted five out the five tested reports lacked documentation of review. Recommendation: We recommend the agency implement procedures to ensure reports are properly reviewed as well as increase training efforts on reporting requirements if ther...

Condition: During our testing of performance reports, we noted five out the five tested reports lacked documentation of review. Recommendation: We recommend the agency implement procedures to ensure reports are properly reviewed as well as increase training efforts on reporting requirements if there is future staffing turnover. Views of responsible officials: Management disagrees with the audit finding. There is review and final approval of these quarterly financial reports by the ELC program director prior to submission. The fiscal analyst at KDHE provides these financial reports to the ELC program manager and the ELC program director. The COVID and CORE ELC data from these reports are manually entered into ELC RedCap (for the years that correspond to this audit) and now ELC CAMP. COVID financial reports are then uploaded into GrantSolutions; the core ELC financial reports do not have to be uploaded to GrantSolutions. There is no mechanism to include a signature on these reports, but submission to ELC CAMP and GrantSolutions indicate the reports have been reviewed. Action taken in response to finding: An email advising reports have been reviewed and approved by the program director will be sent to the program manager as proof the reports have been reviewed/approved and are ready to be submitted. The email will be retained for audit reviews. Name(s) of the contact person(s) responsible for corrective action: Sheri Tubach Planned completion date for corrective action plan: Immediately in March 2024.

View Audit 297874

Finding 384740 (2023-005)

Significant Deficiency 2023

State of Kansas

KS

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) reports, it was noted that the reports were not filed timely or not filed at all for the fiscal year. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Ke...

Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) reports, it was noted that the reports were not filed timely or not filed at all for the fiscal year. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements 8 1 8 0 0 Dollar Amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $ 6,046,626 $ 166,455 $ 6,046,626 $ 0 $ 0 Recommendation: We recommend that KDCF continue with the process implemented during the fiscal year, that includes tracking the timely submission of the FFATA reports. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: KDCF hired a dedicated person in May 2023 to complete the FFATA reporting process. This employee received access to the FSRS website in July 2023 and began entering the FFATA information for new awards. The information captured on the FFATA Checklist and FFATA-5 forms will be used to enter subrecipient information into the FSRS website. Previously, these forms were not always accurate in listing the correct FAIN and amount for each federal award. KDCF has revised this form to include a separate listing for each federal amount awarded and the information will be verified during the concurrence approval process for accuracy. Once concurrence has been completed and any corrections identified, the FFATA reporting details will be added to the FFATA tracking worksheet. KDCF has created a separate tracking worksheet for each state fiscal year which includes separate tabs for each DCF program. This information will be entered into the FSRS website in the reporting month of the award date under each FAIN identified within the required due date. The FFATA information entered will be reviewed on the USA Spending public site for accuracy and corrected as needed. KDCF staff will continue working on updating prior year FFATA information throughout the year identified in previous audits. Name(s) of the contact person(s) responsible for corrective action: Brian Carlgren, Deputy Director of Fiscal Services Addie O’Connell, Grant and Contract Specialist Planned completion date for corrective action plan: July 2024

View Audit 297874

Finding 384738 (2023-004)

Significant Deficiency 2023

State of Kansas

KS

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) report, it was noted that the one report tested was not filed timely. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements 1 0 1 0 0 Dollar Amou...

Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) report, it was noted that the one report tested was not filed timely. Transactions Tested Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements 1 0 1 0 0 Dollar Amount of Tested Transactions Subaward Not Reported Report Not Timely Subaward Amount Incorrect Subaward Missing Key Elements $ 5,850,379 $ 0 $ 5,850,379 $ 0 $ 0 Recommendation: We recommend that KDCF continue with the process implemented during the fiscal year, which includes tracking the timely submission of the FFATA reports. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: KDCF hired a dedicated person in May 2023 to complete the FFATA reporting process. This employee received access to the FSRS website in July 2023 and began entering the FFATA information for new awards. The information captured on the FFATA Checklist and FFATA-5 forms will be used to enter subrecipient information into the FSRS website. Previously, these forms were not always accurate in listing the correct FAIN and amount for each federal award. KDCF has revised this form to include a separate listing for each federal amount awarded and the information will be verified during the concurrence approval process for accuracy. Once concurrence has been completed and any corrections identified, the FFATA reporting details will be added to the FFATA tracking worksheet. KDCF has created a separate tracking worksheet for each state fiscal year which includes separate tabs for each DCF program. This information will be entered into the FSRS website in the reporting month of the award date under each FAIN identified within the required due date. The FFATA information entered will be reviewed on the USA Spending public site for accuracy and corrected as needed. KDCF staff will continue working on updating prior year FFATA information throughout the year identified in previous audits. Name(s) of the contact person(s) responsible for corrective action: Brian Carlgren, Deputy Director of Fiscal Services Addie O’Connell, Grant and Contract Specialist Planned completion date for corrective action plan: July 2024

View Audit 297874

Finding 384736 (2023-003)

Significant Deficiency 2023

State of Kansas

KS

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Condition: During testing of eligibility, the following items were noted: • Two beneficiaries had income entered incorrectly, causing the benefits to be overstated. • One beneficiary had income entered incorrectly but there was no impact on the benefit. • One beneficiary’s income was not entered for...

Condition: During testing of eligibility, the following items were noted: • Two beneficiaries had income entered incorrectly, causing the benefits to be overstated. • One beneficiary had income entered incorrectly but there was no impact on the benefit. • One beneficiary’s income was not entered for consideration, which caused the beneficiary to be incorrectly labeled as eligible. Recommendation: We recommend that KDCF strengthen internal controls in place to mitigate this from happening in the future. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Below are the determined causes for the identified errors. • Failure to review application and supporting documents prior to processing – Case #1 • Failure to double check information that was entered – Case #2 • Failure to review EDBC summary – Case #3 • Failure to adequately document income on the Application Worksheet – where they got income, listing income dates and amounts – Case #4 All causes identified are obviously human error related to lack of attention to detail. In each of the four cases identified, staff reviewed the eligibility determination and corrected as appropriate, including Recovery Accounts established and notices mailed to the household. Corrective action will involve review of training material to determine if there are opportunities to strengthen training material to enhance emphasis on attention to detail for staff receiving the training. Emphasize will also be placed on reviewing material before finalization of case processing to assure accuracy of determination. In addition, the agency is reviewing plans to move from a model that uses several temporary staff that complete only LIEAP eligibility to using full time EES eligibility staff that will do LIEAP in addition to all other EES caseloads. These workers do eligibility for several programs year-round and would not have to be retrained each year. We believe this will improve eligibility determinations and the review and approval process. Name(s) of the contact person(s) responsible for corrective action: Lewis Kimsey, Public Service Executive Shannon Connell, Policy Coordination Assistant Director. Planned completion date for corrective action plan: Training Material finalized by 10/1/24 and that training will be completed by Dec 31, 2024.

View Audit 297874 Questioned Costs: $1

Finding 384733 (2023-005)

Material Weakness 2023

Lake County School District #7

OR

Cash Management Material Weakness School Nutrition Programs

a. Material Weakness - Paid Lunch Equity (NSLP) The District did not calculate its average paid lunch pricing requirement for the fiscal year ended June 30, 2023. b. LCSD7 Plan of Action - New staff hired in July of 2023 has received training from Oregon Department of Education on the calculation pr...

a. Material Weakness - Paid Lunch Equity (NSLP) The District did not calculate its average paid lunch pricing requirement for the fiscal year ended June 30, 2023. b. LCSD7 Plan of Action - New staff hired in July of 2023 has received training from Oregon Department of Education on the calculation process for paid lunch pricing. c. The Business Manager along with the Elementary Principal will ensure this process is complete in June 2024.

View Audit 297873

Finding 384712 (2023-001)

Material Weakness 2023

Harrisburg Area Community College

PA

Student Financial Aid Reporting Material Weakness

Friday, March 15, 2024 Harrisburg Area Community College respectfully submits the following corrective action plan for the year ended June 30, 2023. The findings from the June 30, 2023 audit report dated March 15, 2024 schedule of findings and questioned cost are discussed below. The findings are ...

Friday, March 15, 2024 Harrisburg Area Community College respectfully submits the following corrective action plan for the year ended June 30, 2023. The findings from the June 30, 2023 audit report dated March 15, 2024 schedule of findings and questioned cost are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Agency: (Federal Agency per Finding) U.S. Department of Education Audit Period: July 1, 2022 – June 30, 2023 Name and Address of independent public accounting firm: Smith Elliott Kearns & Company, LLC, Certified Public Accountants & Consultants 804 Wayne Avenue Chambersburg, Pennsylvania Finding Type: (per Finding) Student Financial Aid Cluster: Material Weakness in internal Controls over Compliance and NonCompliance Internal Control Type: (please choose the type per the finding) o Material Weakness(es) o Significant Deficiencies Audit Finding No.: 2023-001 Federal Program: (per Finding) Student Financial Aid Cluster: Compliance Requirement: (per Finding) Reporting Audit Finding Title/Statement of Condition: (copy from audit findings documentation) Institutions are required to report enrollment information under the Pell grant and the Direct loan programs via the National Student Loan Data System (NSLDS). Two student’s enrollment changes were not properly reported to NSLDS and this was not initially addressed by the College. Seven student’s enrollment changes were not timely reported. These students were enrolled during the Spring 2023 semester and the changes were not reported to NSLDS until September 2023, beyond the 60-day reporting requirement. Auditor Recommendation: (copy from audit findings documentation) We recommend that the College ensure all error reports are reviewed and followed up on timely to ensure students information is being properly reported to NSLDS. Additionally, we recommend the college review its policies and procedures and training processes to ensure reporting is happening in a timely manner. Specific steps to be taken to correct the situation [including a timetable for performance of the CAP] or reason why corrective action is not necessary (including disagreement with the finding). 1) The College will correct the enrollment discrepancies that were reported/uncovered in the audit process. 2) The College will review its existing reporting process for enrollment to the National Clearinghouse. 3) The College will regularly cross reference National Clearinghouse reporting to ensure accurate transfer into NSLDS. 4) The College will address any issues with NSLDS reporting carryover/transfer with NSLDS staff support. Anticipated Completion Date: Corrections to the students’ enrollment errors will be addressed by March 31, 2024. Name(s) and Title(s) of contact person(s) responsible for correction action: Tim Barshinger, Assistant Vice-president of Student Enrollment Services

View Audit 297844

Finding 384706 (2023-001)

Significant Deficiency 2023

Massachusetts Maritime Academy

MA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding number: 2023-001 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans AL #’s: 84.268 Award year: 2023 Corrective Action Plan: The Loan Counselor will automatically submit a Direct Loan disbursement report immediately following the disbursement of any federal lo...

Finding number: 2023-001 Federal agency: U.S. Department of Education Programs: Federal Direct Student Loans AL #’s: 84.268 Award year: 2023 Corrective Action Plan: The Loan Counselor will automatically submit a Direct Loan disbursement report immediately following the disbursement of any federal loan. The Director will monitor when the Loan Counselor runs any disbursements and confirm that the disbursement report has been sent to COD in a timely fashion. Timeline for Implementation of Corrective Action Plan: This plan has already been implemented beginning with the 2023-2024 academic year. Contact Person Catherine Kedski, Director of Student Financial Services

View Audit 297824

Finding 384694 (2023-007)

Significant Deficiency 2023

Columbia College

MO

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

2023-007 Exit Counseling (Significant Deficiency) Criteria: Federal regulations stipulate that an institution must ensure that exit counseling is conducted with each Federal Direct Loan borrower shortly before the student borrower ceases at least half-time study at the school. If a student borrower ...

2023-007 Exit Counseling (Significant Deficiency) Criteria: Federal regulations stipulate that an institution must ensure that exit counseling is conducted with each Federal Direct Loan borrower shortly before the student borrower ceases at least half-time study at the school. If a student borrower withdraws from the school without prior knowledge or fails to complete the exit counseling as required, exit counseling must, within 30 days after the school learns that the student has withdrawn from school or failed to complete the exit counseling as required, be provided either through interactive electronic means, by mailing written counseling materials to the student borrower at the student borrower’s last known address, or by sending written counseling materials to an email address provided by the student borrower that is not an email address associated with the school sending the counseling materials. Condition: During our testing, we noted eight instances, in a sample of nine students requiring exit counseling, in which evidence of exit counseling and notification of exit counseling could not be provided by the College. Action Taken: We concur with this finding. Currently, students receive a withdrawal notification that provides them with a link to complete their exit counseling. Moving forward and during the completion of the withdrawal, the students will be presented with an exit counseling digital page. On this page, withdrawal information will be provided to the student along with the deadline to complete the exit counseling. Students will also certify that they have received and understood the information. Once the withdrawal form is completed, students will get a follow up email that will also direct them to the exit counseling at www.studentaid.gov and inform them of the 30-day deadline. Responsible Party: Lola Kennedy, Senior Director of Financial Aid and Sharon Murphy, Registrar Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) and Sharon Murphy, Registrar (smurphy@columbiasc.edu) Expected date of correction: April 1, 2024

View Audit 297799

Finding 384693 (2023-006)

Significant Deficiency 2023

Columbia College

MO

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

2023-006 Return of Title IV Funds (Significant Deficiency) Criteria: When a recipient of Title IV grant or loan assistance withdraws from a school during a payment period in which the recipient began attendance, the school must determine the amount of Title IV assistance earned by the student as of ...

2023-006 Return of Title IV Funds (Significant Deficiency) Criteria: When a recipient of Title IV grant or loan assistance withdraws from a school during a payment period in which the recipient began attendance, the school must determine the amount of Title IV assistance earned by the student as of the student’s withdrawal date. If the total of the Title IV assistance earned by the student is less than the amount that was distributed to the student, the difference must be returned to the Title IV programs. A school must return Title IV funds to the programs from which the student received aid as soon as possible but no later than 45 days after the date of determination of a student’s withdrawal. Condition: From a population of 61 students that withdrew during the fiscal year, we tested seven and noted that six of the seven required a refund calculation and return of funds. Four of the students refund calculations were not completed in a timely fashion and two students that completed a withdrawal form did not have a refund calculations prepared. The College did not return Title IV funds for the two students that should have had refund calculations and the College did not return Title IV funds within 45 days after the date of determination of the student’s withdrawal for the four students that had refund calculations prepared. Action Taken: We concur with this finding. During the 2022-2023 academic year, the Office of Financial Aid experienced much transition. The office is now fully staffed. In addition, the communication list for withdrawals was updated with the Director of Financial Aid’s information to ensure the financial aid office receives all withdrawal information in a timely manner. Responsible Party: Lola Kennedy, Senior Director of Financial Aid Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) Expected date of correction: July 2023

View Audit 297799

Finding 384692 (2023-005)

Significant Deficiency 2023

Columbia College

MO

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

2023-005 Reporting Student Withdraw Date in the National Student Loan Data System (NSLDS) (Significant Deficiency) Criteria: The College is responsible for submitting timely, accurate and complete responses to Enrollment Reporting roster files and for maintaining proper documentation in accordance ...

2023-005 Reporting Student Withdraw Date in the National Student Loan Data System (NSLDS) (Significant Deficiency) Criteria: The College is responsible for submitting timely, accurate and complete responses to Enrollment Reporting roster files and for maintaining proper documentation in accordance with 34 CFR Section 685.309(a)(2). Condition: From a population of 61 students that withdrew during the fiscal year, we tested seven and noted that six of the seven required a refund calculation and return of funds. The change in status was not reported to NSLDS for one student and the last date of the semester was reported instead of the withdrawal date for four students. Action Taken: The Registrar’s Office maintains the institution’s enrollment records. During the fall of 2023, the enrollment reporting process was moved to the Registrar’s Office to ensure the accuracy of reporting. Responsible Party: Sharon Murphy, Registrar Point of Contact: Sharon Murphy, Registrar (smurphy@columbiasc.edu) Expected date of correction: August 2023

View Audit 297799

Finding 384689 (2023-002)

Significant Deficiency 2023

Columbia College

MO

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

2023-002 Disbursement of Title IV Funds (Significant Deficiency) Criteria: An institution must disburse during the current payment period, with certain qualifying exceptions, the amount of Title IV, HEA program funds that a student enrolled at the institution, or the student’s parent, is eligible to...

2023-002 Disbursement of Title IV Funds (Significant Deficiency) Criteria: An institution must disburse during the current payment period, with certain qualifying exceptions, the amount of Title IV, HEA program funds that a student enrolled at the institution, or the student’s parent, is eligible to receive for that payment period, 34 CFR 668.164(b)(1). Condition: During our testing, we noted three instances in a sample of 26 students in which Direct Loan awards were not disbursed to the student during the payment period. Qualified exceptions were not met and the three students received disbursements for the 2022-2023 academic year on August 14, 2023. Action Taken: We concur with this finding. During the 2022-2023 academic year, the Office of Financial Aid experienced much transition. The office is now fully staffed. In addition, the staff attend internal and external training sessions regularly. Currently, disbursements are processed at least 3 times a week. The Office of Financial Aid works diligently to ensure all funds are fully disbursed by the end of each semester. Responsible Party: Lola Kennedy, Senior Director of Financial Aid Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) Expected date of correction: January 2024

View Audit 297799

Finding 384673 (2023-001)

Significant Deficiency 2023

Bristol Community College

MA

Student Financial Aid Matching / Level of Effort / Earmarking

Corrective Action Plan To ensure that there are no further instances of late return of title IV funds due to withdrawals, the financial aid office has updated their process. As a quality assurance measure, every withdrawal processed by the Registrar’s office will be sent to three individuals in the ...

Corrective Action Plan To ensure that there are no further instances of late return of title IV funds due to withdrawals, the financial aid office has updated their process. As a quality assurance measure, every withdrawal processed by the Registrar’s office will be sent to three individuals in the FA office- Director, Associate Director, and Withdrawal Coordinator. After the final withdrawal report from the Registrar’s office has been processed each semester, all students will be reviewed individually by Director, Associate Director, and Coordinator. The manual review process will ensure that all reported students have been appropriately reviewed and processed within the required timeframe. This updated process will eliminate the human error associated with the finding. Timeline for Implementation of Corrective Action Plan Implemented Fall 2023 Contact Person: Alaina Marcotte, Director Financial Aid

View Audit 297771

Finding 384657 (2023-001)

Significant Deficiency 2023

Caddo Hills School District

AR

Special Tests & Provisions Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Contact person: Deric Owens, Superintendent

View Audit 297730

Finding 384657 (2023-001)

Significant Deficiency 2023

Caddo Hills School District

AR

Special Tests & Provisions Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

The District will ensure that contracts are obtained and all applicable construction contracts will contain the required notification regarding compliance with the Davis-Bacon Act. Copies of the weekly-certified payrolls will be obtained for the applicable projects. When bids involving Federal funds...

The District will ensure that contracts are obtained and all applicable construction contracts will contain the required notification regarding compliance with the Davis-Bacon Act. Copies of the weekly-certified payrolls will be obtained for the applicable projects. When bids involving Federal funds are solicited, only those contracts with documentation of Davis Bacon will be considered for the project.

View Audit 297730

Finding 384657 (2023-001)

Significant Deficiency 2023

Caddo Hills School District

AR

Special Tests & Provisions Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Completion date: Immediately upon the next execution of a contract that involves expenditures paid from a Federal Fund.

View Audit 297730

Finding 384656 (2023-002)

Significant Deficiency 2023

City of St. Louis Municipal Library District

MO

Equipment & Real Property Management Special Tests & Provisions Subrecipient Monitoring

Finding No. 2023-002 Significant Deficiency Personnel Responsible for Corrective Action: Jim Slattery, Chief Financial Officer Anticipated Completion Date: March 31, 2024 Corrective Action Plan: Management for the St. Louis Public library will review all processes associated with checking out equipm...

Finding No. 2023-002 Significant Deficiency Personnel Responsible for Corrective Action: Jim Slattery, Chief Financial Officer Anticipated Completion Date: March 31, 2024 Corrective Action Plan: Management for the St. Louis Public library will review all processes associated with checking out equipment and make necessary revisions to processes and procedures to ensure all staff are properly trained to successfully execute all transactions

View Audit 297725

Finding 384655 (2023-001)

Significant Deficiency 2023

City of St. Louis Municipal Library District

MO

Equipment & Real Property Management Special Tests & Provisions Subrecipient Monitoring

Finding No. 2023-001 Significant Deficiency Personnel Responsible for Corrective Action: Jim Slattery, Chief Financial Officer Anticipated Completion Date: March 31, 2024 Corrective Action Plan: Management for the St. Louis Public library will review all processes associated with checking out equipm...

Finding No. 2023-001 Significant Deficiency Personnel Responsible for Corrective Action: Jim Slattery, Chief Financial Officer Anticipated Completion Date: March 31, 2024 Corrective Action Plan: Management for the St. Louis Public library will review all processes associated with checking out equipment and make necessary revisions to processes and procedures to ensure all staff are properly trained to successfully execute all transactions

View Audit 297725

Finding 384654 (2023-001)

Material Weakness 2023

Cordell Independent School District #78

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

To address the specific points highlighted in your recommendation we will: 1. Insert Prevailing Wage Clauses - We will work closely with our legal and procurement teams to incorporate prevailing wage clauses consistently in all relevant contracts. This will be a standard practice for any construct...

To address the specific points highlighted in your recommendation we will: 1. Insert Prevailing Wage Clauses - We will work closely with our legal and procurement teams to incorporate prevailing wage clauses consistently in all relevant contracts. This will be a standard practice for any construction project that involves federal awards. 2. Effective Monitoring Process - We acknowledge the importance of a rigorous monitoring process. To this end, we will develop and implement a comprehensive system to monitor compliance with contractual obligations, including regular checks to ensure that federal wage rates and fringes are met. This monitoring process will involve thorough reviews of weekly certified payroll reports submitted by contractors and subcontractors. 3. Work Site Compliance - Recognizing the significance of visible compliance, we will mandate the posting of all relevant items, such as wage rates and project details, at prominent locations on the work site. This measure aims to enhance transparency and serves as a tangible demonstration of our commitment to Davis-Bacon Act compliance. We understand the critical nature of adhering to federal regulations and appreciate your guidance in strengthening our internal controls. We will initiate these changes promptly, ensuring that they are integrated into our standard operating procedures for all future construction projects involving federal awards. Additionally, we welcome any further guidance or collaboration in this regard and are open to periodic reviews to ensure ongoing compliance. Our commitment to upholding the principles of the Davis-Bacon Act aligns with our dedication to transparent and ethical practices. Thank you once again for your valuable recommendations, and we look forward to implementing these measures in collaboration with your guidance.

View Audit 297724

Corrective Action Plans

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