Corrective Action Plans

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Finding 395808 (2023-001)
Significant Deficiency 2023
Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a mod...
Person responsible for corrective action Emily Allen, SVP Programs Corrective Action The Foundation concurs with this finding. We have worked with the U.S. Department of Labor and the matter is now closed. In February 2024, the Foundation repaid the $435,289 identified in this finding, and a modified final report has been filed. The Foundation will design and implement additional processes to ensure that earmarking requirements are monitored on a continuous basis by SCSEP staff. In the meantime, the Foundation has implemented additional controls to address the risks of noncompliance with earmarking requirements. Beginning with the March 2024 quarterly report (which was filed on April 9, 2024), all such reports will be reviewed by the Group Controller and Assistant National Director, SCSEP, with specific reference to the earmarking requirements. In the event of any report identifying a risk of noncompliance with the earmarking requirements, the Foundation will immediately raise the matter with our colleagues at the U.S. Department of Labor. Anticipated Completion Date Initial implementation completed, with further control enhancements to be in place by June 30, 2024
View Audit 305433 Questioned Costs: $1
CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Progra...
CORRECTIVE ACTION PLAN Federal Award Findings and Questioned Costs Finding 2023-001 Student Financial Aid Cluster: Assistance Listing #84.007 Federal Supplemental Educational Opportunity Grants Assistance Listing #84.033 Federal Work-Study Program Assistance Listing #84.063 Federal Pell Grant Program Assistance Listing #84.268 Federal Direct Student Loans Assistance Listing #93.364 Nursing Student Loans Federal agency – U.S. Department of Education Grant Period – Year ended August 31, 2023 Compliance Requirement: Special Tests and Provisions Criteria: The Gramm-Leach-Bliley Act (Public Law 106-102) (GLBA) requires the College, on an annual basis, to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of customer (student) information that could result in the unauthorized disclosure, misuse, alteration, destruction, or other compromise of such information, and assess the sufficiency of any safeguards in place to control these risks. At a minimum, the GLBA risk assessment should include consideration of risk in each relevant area of operations, including: Employee training and management. Information systems, including network and software design, as well as information processing, storage, transmission, and disposal. Detecting, preventing, and responding to attacks, intrusions, or other system failures. Condition: During our testing, we noted the following: While the IT Systems Team is the assigned resource for information security matters, the College communicated that it does not have a single qualified individual designated with the responsibility for implementing and enforcing the College’s information security program. An annual IT risk assessment was not performed. A vendor management program is not in place. Mobile device management is not in place. Backup media is not encrypted. A full set of policies and procedures is not in place. Cause: The expected documentation supporting the required controls to adequately confirm compliance with GLBA safeguards was not complete. Effect: Without demonstrable, documented controls supporting compliance with the GLBA standards for safeguarding the protected data, compliance with the law and the requirements in the federal PPA may not be assured. Context: Inquiry and observation of the information received from the College related to compliance with GLBA. Recommendation: The College should review the GLBA safeguarding rules and as soon as practical implement and document the controls necessary for compliance with the rule, focusing on the completion of a documented, thorough, and standardized risk assessment and management reporting framework. The College should perform comprehensive risk assessments on a regular basis, which is suggested to be at least annually, and at any significant change in infrastructure or business process. Contact Person Responsible for Corrective Action Plan: Donna Rocap, Associate Vice President of Administration Corrective Action Plan: The College agrees with the findings and is in process of developing a corrective action plan to address. In addition, the College has made it a top priority to hire both a Chief Information Officer and a Chief Information Security Officer but has experienced difficulty getting a qualified pool of candidates. Timing of Planned Corrective Action: The College expects to resolve this finding during its August 31, 2024 fiscal year.
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2024
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report ...
Name of the Contact Person Responsible for the Corrective Action Plan: Stacey Merritt, Interim Finance Director Corrective Action Plan: Management concurs with the finding. We will work to ensure that future reports are submitted timely and that evidence of submissions is retained for each report filing. Anticipated Completion Date: June 30, 2024
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.
Finding 395578 (2023-002)
Significant Deficiency 2023
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as...
Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as $13,011,879, rather than $12,930,176. Total lost revenues available to be used in this reporting period based on the adjusted amount was $7,142,168 on payments in the period of $7,142,168. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management increased the level of review over the lost revenue calculations for future reporting periods. Management did not believe that further corrections to the Period 4 report were necessary as the remaining available lost revenues after adjusting for the error were equal to the payments received in the period and there was no further submissions necessary for Robert Parker Hospital. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: September 30, 2023
Finding 395577 (2023-001)
Significant Deficiency 2023
Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have inc...
Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have increased the allowable costs eligible for reimbursement under the Federal award by $671. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management implemented an enhanced review process to validate all amounts reported on the PRF Reporting Portal Submission, and to ensure compliance with existing policies and terms and conditions of the Provider Relief Funds. Further action was not considered necessary as the errors would result in increased costs eligible for reimbursement under the Federal award and no further funding is available. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: This was corrected as of June 30, 2023, and the pay for event program was phased-out after the final Provider Relief Funds were released.
Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in questio...
Institutional Comments on Findings and Recommendations: The institution agrees with the auditor on this finding in that there were (3) three cases where the enrollment status was not reported correctly. Although as was observed by the auditor, the enrollment status for the three students in question were corrected in the next enrollment report that was submitted. During the audit period, the institution was unable to update, submit or complete in a timely manner Enrollment reports for the period of July through December 2022. This was mainly due to problems with the implementation of a new format for enrollment reporting through the NSLDS Modernized Website. The institution has on file, multiple inquiries to the NSLDS Customer Support Center in relation to this issue. The Department of Education also posted various Electronic Announcements updating and giving continued guidance to institutions on this issue. The auditors were provided with copies of all of ED’s posting and updates as related to this issue. Nevertheless, during the subsequent months from January 2023 to June 2023 covered in this audit period, the institution was able to complete and report the current enrollment status of students to the NSLDS platform. Actions Taken or Planned: The matter as related to this finding has already been discussed with the Registrar who is responsible for the completion and submission of the Enrollment Reports to the Department of Education To continue to improve on the reporting to student’s enrollment status, the institution would continue to submit its Enrollment Reports monthly instead of every two months as schedule. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the stud...
Institutional Comments on Findings and Recommendations: Compliance Requirements – Applicable After a Student Begins Attendance: The institution agrees with the auditors on this finding in which there were two (2) cases where the auditors noted that the institution failed to determine that the students withdrew within fourteen (14) days after the student’s last day of attendance. In one (1) of the two (2) cases the Date of Determination was twenty-two (22) days after the Last Day of Attendance and in the second case, the Date of Determination was Three (3) days after the Last Day of Attendance. All funds due to the Department, (for the first case $682.00 of Unsub. Direct Loan funds and in the second case $974.22 of Federal Pell Grant funds), were returned within the forty-five (45) days required timeframe as of the Date of Determination of each case. This process was evidenced to the auditors for their records. Actions Taken or Planned: The institution is fully aware of the Return of Title IV funds (R2T4) reporting requirements and deadlines. The issue related to this finding was identified as a lack in some Faculty notifying student absences within the fourteen (14) day timeframe to process an R2T4 in a timely manner as required. Although this issue was already discussed with them by the Dean of Academic Affairs, an additional follow up meeting would be held to remind them of the importance in monitoring student attendance and notifying student absences to the Registrar office within the required timeframes to fully comply with the R2T4 reporting requirements. Status of Corrective Actions on Prior Findings: The issue as related to this finding occurred in the past audit.
View Audit 305178 Questioned Costs: $1
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to disbursing loans within aggregate loan limits. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to competing and submitting the audit. The College has a new CFO and Controller. These measures will ensure stability and a timely audit. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective immediately and ongoing
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial ...
Management concurs with this finding. The College will adhere to its policies, procedures, processes, and federal guidelines as it relates to over awarding students. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to students meeting satisfactory academic progress. The College has an SAP appeal committee in place to enforce and abide by the College's policy. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Direct...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to disbursing and administering federal aid. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid, Chief Financial Officer & V.P. of Academic Affairs Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Regist...
Management concurs with this finding. The College will set policies, procedures and practices in place and adhere to ensure that changes in students’ enrollment are reported accurately and timely as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Registrar Effective: Immediately and ongoing
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guid...
Management concurs with this finding. The College will review and adhere to its practices, policies, and procedures along with federal regulations as it relates to resolving credit balances. The College will resolve credit balances timely and within the 14-day period as defined in the Federal guidelines. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
Management concurs with this finding. The College will ensure the accuracy of the data that is input into the COD system and the College will work to apply funds appropriately to students' accounts. The College will review and adhere to its practices, policies, and procedures along with federal gu...
Management concurs with this finding. The College will ensure the accuracy of the data that is input into the COD system and the College will work to apply funds appropriately to students' accounts. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to managing the COD system. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal gui...
Management concurs with this finding. The College will keep accurate attendance and participation records. The College will calculate R2T4s accurately and will return the funds in a timely manner. The College will review and adhere to its practices, policies, and procedures along with federal guidelines as it relates to R2T4 regulations. The College will return any ineligible funds accordingly. Responsible Administrators: Director of Financial Aid & Chief Financial Officer Effective: Immediately and ongoing
View Audit 305169 Questioned Costs: $1
Finding 395409 (2023-002)
Significant Deficiency 2023
Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur wi...
Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur with the recommendation and are in the process of creating a single, succinct schedule and the supporting documentation on indirect cost rates and rationale to allow the auditors to easily verify that the costs have been charged appropriately.
Finding 395368 (2023-038)
Significant Deficiency 2023
2023-038 Department of Early Learning and Care Retain support and improve controls over reporting MANAGEMENT RESPONSE: We agree with this recommendation. DELC will work with the Department of Revenue to substantiate the amount of tax credits used in prior years to meet federal matching and mainte...
2023-038 Department of Early Learning and Care Retain support and improve controls over reporting MANAGEMENT RESPONSE: We agree with this recommendation. DELC will work with the Department of Revenue to substantiate the amount of tax credits used in prior years to meet federal matching and maintenance of effort requirements for FY 20 to FY 22 and ensure this information is retained appropriately outside beyond just email records. In addition, DELC will update processes and procedures to ensure that tax credit amounts used in future reports are properly documented and substantiated by the Department of Revenue. Anticipated Completion Date: October 31, 2024 Contact person: Ali Webb, Operations and Policy Analyst; Connie Range, Fiscal Analyst
Finding 395362 (2023-021)
Significant Deficiency 2023
2023-021 Oregon Health Authority Implement controls to ensure earmarked expenditures are tracked and compliance achieved MANAGEMENT RESPONSE: We agree with this recommendation. As noted in the audit report, OHA has already taken corrective actions to ensure controls are in place for tracking app...
2023-021 Oregon Health Authority Implement controls to ensure earmarked expenditures are tracked and compliance achieved MANAGEMENT RESPONSE: We agree with this recommendation. As noted in the audit report, OHA has already taken corrective actions to ensure controls are in place for tracking applicable expenditures in SFMA to ensure compliance with federal Earmarking requirements. The Office of Financial Services, OHA Budget Unit, and block grant planners meet at least once a month to review budgeted earmarked requirements and expenditures to ensure compliance. Block grant planners meet at least once a month with the crisis team and children and family team to review required earmark budgets and expenditures. Anticipated Completion Date: June 30, 2023 Contact person: Annabelle Atalig, Budget and Fiscal Manager; Travis Labrum, Grant Accounting Manager
Finding 395355 (2023-018)
Significant Deficiency 2023
2023-018 Oregon Housing and Community Services Ensure grant management report control is performed and documented MANAGEMENT RESPONSE: We agree with this recommendation. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training h...
2023-018 Oregon Housing and Community Services Ensure grant management report control is performed and documented MANAGEMENT RESPONSE: We agree with this recommendation. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training has been provided for awareness of the earmarking and obligation requirements as well. Anticipated Completion Date: June 30, 2024 Contact person: Dean Criscola, Controller
2023-025 Department of Human Services Obtain accurate information from the ONE application MANAGEMENT RESPONSE: We agree with this recommendation. The department continues to monitor and review ACF-199 and ACF-209 reports prior to submission. Defects identified through the monitoring and review p...
2023-025 Department of Human Services Obtain accurate information from the ONE application MANAGEMENT RESPONSE: We agree with this recommendation. The department continues to monitor and review ACF-199 and ACF-209 reports prior to submission. Defects identified through the monitoring and review process are logged into TFS and follow the defect management process. ONE/ODHS began SOC audit with an outside vendor at the end of 2023. The department is continuing to work through the items and anticipate completion with this audit by June 30, 2024. The department will share the findings once received if there are any. SOC audits will be done annually from here forward. The Agency provided a cure notice to Deloitte Consulting as the vendor related to the reports in December 2022 and considered the actions cured and removed the notice in July 2023. Quarterly reports sent through the contract have been provided and accepted by ACF. Defect triaging continues to be worked separately, and regular reports to verify changes, additional validations that were put into place, achieve expected quality in correct submission of data on behalf of Oregon from the ONE System. Anticipated Completion Date: December 31, 2024 Contact person: Xochitl Esparza, Program Administration Manager
2023-040 Oregon Department of Education State did not meet maintenance of effort requirement MANAGEMENT RESPONSE: We agree with this recommendation. The Department of Education agrees with this finding; however, context is critical to understand this requirement. The Maintenance of Effort (MOE) r...
2023-040 Oregon Department of Education State did not meet maintenance of effort requirement MANAGEMENT RESPONSE: We agree with this recommendation. The Department of Education agrees with this finding; however, context is critical to understand this requirement. The Maintenance of Effort (MOE) requirements in The ARP ESSER III legislation are unique. The purpose of the requirement is to ensure that states are not using the federal pandemic funds to replace state funding and then leaving districts with a more substantial “fiscal cliff” when the pandemic funds recede. ODE administers state funding to Oregon districts, but the levels and formulas governing the distribution of the total state funds are determined by the Oregon Legislature and not ODE. While the non-compliance finding implies that Oregon reduced education funding, that is not true. Education funding in Oregon did increase annually, yet not as much as other non-education funding priorities. The United States Department of Education (USDE) formula required to evaluate MOE does not adequately reflect the investment in public education in Oregon, nor does it acknowledge the complexities of Oregon’s state budget or school funding formulas. ODE worked closely with USDE staff monitoring MOE compliance and submitted a request to USED for an MOE waiver on March 14, 2024. We are awaiting a decision from USDE. A response is anticipated by June 2024. Anticipated Completion Date: June 30, 2024 Contact person: Cynthia Stinson, Senior Manager of Federal Investments and Pandemic Renewal Effort
2023-015 Oregon Housing and Community Services Fully implement controls to ensure subrecipients are in compliance with program requirements MANAGEMENT RESPONSE: We agree with this recommendation. OHCS has hired an outside contractor to complete the requested work. Contractor was not in place in...
2023-015 Oregon Housing and Community Services Fully implement controls to ensure subrecipients are in compliance with program requirements MANAGEMENT RESPONSE: We agree with this recommendation. OHCS has hired an outside contractor to complete the requested work. Contractor was not in place in time to complete action prior to end of audit work, however work will be finalized prior to the end of the current fiscal year. Anticipated Completion Date: June 30, 2024 Contact person: Dean Criscola, Controller
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