Corrective Action Plans

Finding 6417 (2023-004)

Material Weakness 2023

SD

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

Finding 2023-004 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Test and Provisions Finding Summary: The Hospital's reserve account is fully funded per the requir...

Finding 2023-004 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Test and Provisions Finding Summary: The Hospital's reserve account is fully funded per the requirements in the loan resolution agreement. However, there is no documented secondary monitoring of the account balance as compared to the required minimum balance. Responsible Individuals: Lisa Weisser, Director of Finance Corrective Action Plan: A qualifying statement will be added to the bi-monthly board report which will qualify the minimum USDA-RD required reserve balance for the board of director's review and oversight. Anticipated Completion Date: January 2024

View Audit 8344

Finding 6416 (2023-003)

Material Weakness 2023

Wagner Community Memorial Hospital

SD

Reporting Material Weakness Matching / Level of Effort / Earmarking

Finding 2023-003 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: The Hospital does not have an i...

Finding 2023-003 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: The Hospital does not have an internal control system designed to provide for the preparation of the schedule and notes to the schedule. We requested our auditors to assist with the preparation of the schedule and notes to the schedule. Responsible Individuals: Lisa Weisser, Director of Finance Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the Schedule of Expenditures of Federal Awards. We requested that our auditors, Eide Bailly LLP, prepare the Schedule of Expenditures as part of their Single Audit. We have designated members of management to review the drafted Schedule and accompanying notes. Anticipated Completion Date: Ongoing

View Audit 8344

Finding 6397 (2023-004)

Significant Deficiency 2023

Greene County Medical Center

IA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Finding 2023-004: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: The Medical Center excluded adjustments from t...

Finding 2023-004: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: The Medical Center excluded adjustments from the lost revenue calculation. Responsible Individuals: Mark Wall, CFO Response: The Medical Center agrees with the findings. We will utilize our outside accounting firm for guidance to ensure appropriateness of calculations going forward. Completion Date: Ongoing

View Audit 8319

Finding 6377 (2023-004)

Material Weakness 2023

Purchase Area Development District

KY

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment

The Purchase ADD has been going through a transition period between personnel, accounting software and audit firms the last three years. As a result, this transition has caused the ADD to continually adapt policies & procedures for correctness. The report to EDA by the loan staff included loans th...

The Purchase ADD has been going through a transition period between personnel, accounting software and audit firms the last three years. As a result, this transition has caused the ADD to continually adapt policies & procedures for correctness. The report to EDA by the loan staff included loans that had been approved in FY 2023 but not yet closed. In the future, loan staff and finance staff need to coordinate more closely what is being reported to avoid discrepencies. Fortunately, all funding as accounted for and used for its intended purpose.

View Audit 8239

Finding 6373 (2023-002)

Material Weakness 2023

King's College

PA

Student Financial Aid Material Weakness Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The College had internally identified the failure to send the required notifications in January 2023 and took corrective action to create new processes and made system adjustments effective for the fa...

Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The College had internally identified the failure to send the required notifications in January 2023 and took corrective action to create new processes and made system adjustments effective for the fall 2023 semester. All required notifications were made for fall 2023 disbursements. The College is evaluating alternate notification processes to improve efficiencies and ensure completeness. Names of Contact Persons Responsible for Corrective Action: Barbara Schmitt, Director of Financial Aid Anticipated Completion Date: Changes were effective for the fall 2023 semester

View Audit 8234

Finding 6372 (2023-001)

None 2023

King's College

PA

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The Associate Director of Financial Aid is responsible for calculating Return of Title IV (R2T4) refunds for all students who withdraw from the College within the first 60% of the payment period using...

Views of Responsible Officials and Planned Corrective Actions: The College agrees with the finding. The Associate Director of Financial Aid is responsible for calculating Return of Title IV (R2T4) refunds for all students who withdraw from the College within the first 60% of the payment period using the Colleague software R2T4 module for calculating refunds. The Director of Financial Aid will provide a secondary review of all calculated R2T4 refunds before funds are returned to the Common Origination and Disbursement system. Names of Contact Persons Responsible for Corrective Action: Barbara Schmitt, Director of Financial Aid Anticipated Completion Date: Changes were effective for the fall 2023 semester

View Audit 8234

Finding 6236 (2023-001)

None 2023

Yeshiva University

NY

Student Financial Aid Eligibility Reporting

Management Views and Corrective Action Plans 2023-001 – Inaccurate Submission of Student Enrollment Change Submissions to the National Student Loan Data System (NSLDS) Point of Contact – Jennifer Spiegel Goldberg, University Registrar, (646-592-6275) Management agrees with the current year finding a...

Management Views and Corrective Action Plans 2023-001 – Inaccurate Submission of Student Enrollment Change Submissions to the National Student Loan Data System (NSLDS) Point of Contact – Jennifer Spiegel Goldberg, University Registrar, (646-592-6275) Management agrees with the current year finding and the recommendations. The Office of the Registrar has recently been reorganized to create a dedicated, Records unit to assure that limited personnel will be responsible for leaves and withdrawals and who will use internal reports available to quality control data input before external reporting. All staff have been retrained to watch for the condition that led to this error when handling requests, including reminder of University policies and procedures. This retraining took place on September 6, 2023. The NSC Roster and NSLDS will be updated by December 29, 2023. We believe this finding will be remediated in fiscal 2024.

View Audit 8211

Finding 6199 (2023-001)

Significant Deficiency 2023

City of Cumberland, Maryland

MD

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Enhance the internal control procedures for the Community Development Block Grant Program to specifically state the requirement for the PR29 Cash on Hand Quarterly Report to be submitted no later than 30 days following each completed quarter and communicate this requirement to the City's finance dep...

Enhance the internal control procedures for the Community Development Block Grant Program to specifically state the requirement for the PR29 Cash on Hand Quarterly Report to be submitted no later than 30 days following each completed quarter and communicate this requirement to the City's finance department employees and Senior Community Development Specialist. Doing so ensures the responsible parties are informed of the requirement and expands the number of responsible parties who are cognizant of and monitoring to ensure this action is completed on time. Additionally, the finance department employees and Senior Community Development Specialist have been advised of the importance of meeting this requirement.

View Audit 8141

Finding 6157 (2023-001)

Significant Deficiency 2023

First 5 San Bernardino

CA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.302

Finding 2023-001 Federal Agency Name: US Department of Health & Human Services, California Department of Social Services Program Name: Child Care and Development Fund Cluster CFDA #93.575 Finding Summary: The Commission has not established written procedures for determining allowability of costs in...

Finding 2023-001 Federal Agency Name: US Department of Health & Human Services, California Department of Social Services Program Name: Child Care and Development Fund Cluster CFDA #93.575 Finding Summary: The Commission has not established written procedures for determining allowability of costs in accordance with Subpart E- Cost principles or the conditions of the Federal award. Responsible Individuals: Debora Dickerson-Sims, Chief Financial Officer Corrective Action Plan: Review current policies and procedures to revise or develop new procedures for determining allowability of costs in accordance with Subpart E – Cost principles or the conditions of the Federal award. Anticipated Completion Date: June 30, 2024

View Audit 8037

Finding 6099 (2023-002)

Significant Deficiency 2023

Columbia International University and Subsidiaries

SC

Student Financial Aid Reporting Significant Deficiency

Inaccurate and Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: In conjunction with the Registrar’s Office, we have implemented the following corrective actions to improve our processes/timeframe for withdrawals: 1) This summer, the Financial Aid Office was added to the workfl...

Inaccurate and Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: In conjunction with the Registrar’s Office, we have implemented the following corrective actions to improve our processes/timeframe for withdrawals: 1) This summer, the Financial Aid Office was added to the workflow in Etrieve (document management system used by CIU) so that 2 of our counselors (one for UG trad and one for online) now receive notifications directly of every withdrawal received by the Registrar’s Office. This allows our office to begin the process of returning funds without the reliance of emails forwarded from the Registrar’s Office. 2) Director and Associate Directors of Financial Aid met with the Registrar and Assistant Registrar on 10/31/23 to discuss how communication and processes could improve between offices. The following are several action items the Registrar will complete on their end that can assist in accomplishing this goal. • Registrar will ask Deans to explain to their faculty that when a student completes an assignment after their module is complete, the date to be entered must be the last date of that module so that our reports will capture the date needed for the return to process correctly. • Registrar will review their current procedures for processing official withdrawals and tighten their turn around time so that the Financial Aid Office can return aid within the required 45 days. 3) CIU made the decision to convert all 5-week UG online classes to 8-week classes starting the 23-24 academic year. These modules now fall within our standard academic calendar which should greatly improve our ability to monitor and process withdrawals for this student population. Person Responsible for Corrective Action Plan: Patty Hix, Director of Financial Aid; Lynsay Shumpert, Associate Director for Online Studies; Elizabeth Haselden, Registrar Anticipated Date of Completion: A follow-up meeting has been set before the end of fall semester to discuss the progress of our action plans with the Registrar.

View Audit 7973

Finding 6060 (2023-001)

None 2023

Housing Authority of Savannah

GA

Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment

Management has implemented, and is in the process of implementing, specific corrective actions to address each of HUD’s Findings. The Authority’s Deputy Director, Kenneth Clark has assumed the responsibility of implementing the specific corrective actions and anticipates complete implementation by ...

Management has implemented, and is in the process of implementing, specific corrective actions to address each of HUD’s Findings. The Authority’s Deputy Director, Kenneth Clark has assumed the responsibility of implementing the specific corrective actions and anticipates complete implementation by March 31, 2024.

View Audit 7953 Questioned Costs: $1

Finding 5784 (2023-002)

Significant Deficiency 2023

Simpson University

CO

Student Financial Aid Allowable Costs / Cost Principles Significant Deficiency

Need Analysis Planned Corrective Action: The University recognizes the federal regulations regarding over‐awarding and has implemented the use of a delivered report through the Student Information System to address this concern. Person Responsible for Corrective Action Plan: Shondra Dickson, Direc...

Need Analysis Planned Corrective Action: The University recognizes the federal regulations regarding over‐awarding and has implemented the use of a delivered report through the Student Information System to address this concern. Person Responsible for Corrective Action Plan: Shondra Dickson, Director of Financial Aid Anticipated Date of Completion: Implemented

View Audit 7877

Finding 5746 (2023-005)

Significant Deficiency 2023

Sterling College

KS

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

Finding 2023-005: Reporting of disbursement dates to the Common Origination and Disbursement system Contact person responsible for correction action – Mitzi Suhler, Vice President of Enrollment Services Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with t...

Finding 2023-005: Reporting of disbursement dates to the Common Origination and Disbursement system Contact person responsible for correction action – Mitzi Suhler, Vice President of Enrollment Services Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding regarding the disbursement dates of two students who were reported incorrectly to the COD system. We will provide continued training to those who are responsible for compliance of reporting accurate disbursement dates. We will review processes and internal controls and make any necessary changes to prevent and/or detect issues so that they can be corrected in a timely manner.

View Audit 7826

Finding 5743 (2023-002)

Material Weakness 2023

Sterling College

KS

Questioned Costs Student Financial Aid Eligibility

Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding of the under award and over award of federal aid for two students. During the 2022-2023 year we hired new ...

Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding of the under award and over award of federal aid for two students. During the 2022-2023 year we hired new financial aid staff that required significant training in the regulations of financial aid. Although checks and balances were in place these two instances were overlooked. Continued training, along with improved checks and balances through our updated software system, will enable the financial aid office to avoid issues with under and over-awarding federal student aid. The office will perform periodic reviews of awarding through reports from the system that will flag students who have potentially been under or over awarded federal aid.

View Audit 7826 Questioned Costs: $1

Finding 5742 (2023-001)

Material Weakness 2023

Sterling College

KS

Student Financial Aid Reporting Material Weakness

Finding 2023-001: Enrollment Reporting Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding. A review of enrollment reporting is being done at the end of each...

Finding 2023-001: Enrollment Reporting Contact person responsible for correction action – Mitzi Suhler, Financial Aid Director Anticipated completion date – June 30, 2023 Corrective action Sterling College agrees with the finding. A review of enrollment reporting is being done at the end of each semester with particular attention being paid to students who have withdrawn during the semester or graduated at the end of the term. Along with reviewing those students, a random list of students that are not a part of the withdrawal or graduation list are being chosen for review, and if no student enrollment is found to be reported inaccurate, no further review is required per our policy. We feel that there are some changes soon that will help us with our enrollment reporting. One of them is that Sterling College is implementing a new version of our software system, Jenzabar, in 2024. This system will have better checks and balances for enrollment reporting, cleaner data, and will enable the College to have more accurate reporting. There will still be a need to do a review of each semester’s enrollment reporting. The financial aid office will review all student enrollment records that are enrolled for the semester to ensure the reporting dates are correct from this point forward. Once we have confidence that the system is doing what is expected, we will adjust the review to a random list of students.

View Audit 7826

Finding 5741 (2023-001)

Material Weakness 2023

Deliverance Manor Housing Corporation

IL

Questioned Costs Student Financial Aid Cash Management

CORRECTIVE ACTION PLAN Finding No. 2023-01: Credit Card was not reconciled and receipts were not obtained. Expenses were not properly recorded in the general ledger. Recommendation: Management should reconcile credit card accounts monthly and secure receipts for purchases and expenses should be post...

CORRECTIVE ACTION PLAN Finding No. 2023-01: Credit Card was not reconciled and receipts were not obtained. Expenses were not properly recorded in the general ledger. Recommendation: Management should reconcile credit card accounts monthly and secure receipts for purchases and expenses should be posted to the proper general ledger account. Action Taken or Planned: Credit card accounts will be reconciled and receipts will be requested for purchases. Accounting will review the nature of purchases and properly post to the general ledger. Responsible Person: Mary Amador, Property Manager Completion Date: October 31, 2023

View Audit 7824 Questioned Costs: $1

Finding 5737 (2023-002)

None 2023

Marietta College

OH

Special Tests & Provisions Student Financial Aid Matching / Level of Effort / Earmarking

The College will examine the document destruction date on student related files related to federal compliance requirements to ensure accuracy of the document destruction date and accuracy of student files.

View Audit 7807

Finding 5734 (2023-003)

Significant Deficiency 2023

Raton Public School District No. 11

NM

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

Specific corrective action plan for finding: Continue to train staff on proper purchasing procedures Timeline for completion of corrective action plan: February 1, 2024 Employee position(s) responsible for meeting the timeline: Myra Baird and Robin Martinez

View Audit 7795

Finding 5730 (2023-003)

Significant Deficiency 2023

Independent School District No. 32

MN

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

Contact Person – Mark Lundin, Superintendent Corrective Action Plan – The District will review polices and procedures for submitted certified payrolls. Completion Date – November 1, 2023

View Audit 7783

Finding 5693 (2023-001)

Significant Deficiency 2023

Buena Vista University

IA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

2023 Corrective Action Plan Finding Reference Number 2023-001 Contact person - Stephanie Wilhelm, Registrar Cause - Management oversite during a status update report submission Current Status - All student enrollment statuses from spring 2023 semester has been reviewed and corrected as needed. All s...

2023 Corrective Action Plan Finding Reference Number 2023-001 Contact person - Stephanie Wilhelm, Registrar Cause - Management oversite during a status update report submission Current Status - All student enrollment statuses from spring 2023 semester has been reviewed and corrected as needed. All students that graduate at mid semester will be reviewed individually to ensure that they are not re-reported as enrolled after degree completion. We have also updated our conferring process to add a status flag to ensure the graduated status is sent to NSC-NSLDS for updates. For those students that begin our graduate program immediately after completing the undergraduate program, they will be managed individually for reporting mid-stream until the new term begins. Views of Responsible Officials and Planned Corrective Action - the software cause of the re-reportig of graduated students as enrolled has not been determined. All mid-term graduate prior to March 2023 worked correctly and those that graduated July 2023 all worked correctly. Reports have been created for mid-term graduates and students begining another program immediately after degree completion. Anticipated Completion Date - Already completed and ongoing.

View Audit 7684

Finding 5649 (2023-001)

Significant Deficiency 2023

Dordt University, Inc.

IA

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions

Finding 2023-001 - Special Tests and Provisions – Gramm-Leach-Bliley Act Responsible Individuals – Director of Computer Services and Vice President for Finance & Risk Management. Finding Summary: During testing of Gramm-Leach-Bliley Act and inquiry with management, it was determined that the Univ...

Finding 2023-001 - Special Tests and Provisions – Gramm-Leach-Bliley Act Responsible Individuals – Director of Computer Services and Vice President for Finance & Risk Management. Finding Summary: During testing of Gramm-Leach-Bliley Act and inquiry with management, it was determined that the University does not have a written comprehensive information security program in place. Corrective Action Planned: Dordt will be working with an external organization familiar with the policy requirements of the Gramm-Leach-Bliley Act to take existing procedures and incorporate them into a formal written information security policy that addresses the key areas of the Gramm-Leach-Bliley Act. Anticipated Completion Date: June 30, 2024.

View Audit 7569

Finding 5644 (2023-002)

Significant Deficiency 2023

Saint Martin's University

WA

Internal Control / Segregation of Duties Student Financial Aid Significant Deficiency

Action taken: Saint Martin’s University will review the requirements of 16 CFR 314.4, update our written policy to ensure that it addresses all the required elements 16 CFR 314.3(b), and perform an annual review of our updated policy to ensure that it continues to comply with all relevant regulation...

Action taken: Saint Martin’s University will review the requirements of 16 CFR 314.4, update our written policy to ensure that it addresses all the required elements 16 CFR 314.3(b), and perform an annual review of our updated policy to ensure that it continues to comply with all relevant regulations. The University is currently in the process of formally adopting a cybersecurity framework as well as securing a vendor to perform an IT security assessment. This ongoing work in the interest of the security, confidentiality, and integrity of student information will position us well to make the recommended updates to our policy Name of Responsible Party: Mary Donahoo, Chief Information Officer Anticipated completion date: 3/31/2024

View Audit 7568

Finding 5642 (2023-001)

Significant Deficiency 2023

Saint Martin's University

WA

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

Action taken: As of June 2023, the Financial Aid department has a full-time Director, who is responsible for the Return to Title IV (R2T4) determinations. Following the regulations set forth by the Department of Education on R2T4 calculations for schools not required to take attendance, we have revi...

Action taken: As of June 2023, the Financial Aid department has a full-time Director, who is responsible for the Return to Title IV (R2T4) determinations. Following the regulations set forth by the Department of Education on R2T4 calculations for schools not required to take attendance, we have reviewed procedures and controls to ensure they are properly designed and implemented to ensure calculations are occurring accurately and timely. Going forward, we will ensure maintenance of proper documentation on students requiring a calculation, including indication of withdrawal date. Potential R2T4 calculations audits are now run multiple times a week, and will continue to be, in order to address timely calculations. The Director plans to continue education in the area of R2T4 calculations to maintain the most accurate and updated information on the topic. Name of Responsible Party: Erin Schaffer, Director of Financial Aid Anticipated completion date: 12/31/2023

View Audit 7568

Finding 5627 (2023-002)

Significant Deficiency 2023

County of Fairfax, Virginia

VA

HUD Housing Programs Eligibility Reporting § 200.303

Views of responsible officials and planned corrective actions: The Authority is working with Yardi, the software company that supports the Authority’s client management software, to provide standardized reports that can be used by managers to flag exceptions to requirements such as regular inspectio...

Views of responsible officials and planned corrective actions: The Authority is working with Yardi, the software company that supports the Authority’s client management software, to provide standardized reports that can be used by managers to flag exceptions to requirements such as regular inspections, and re-inspections within 30 days for units that fail due to non-life-threatening conditions. There are current limitations within the software that do not allow for a fully automated work flow, which then necessitates a highly manual process and more likelihood of human error. The Authority will also implement more internal controls at the management level; specifically with units that fail inspection. All failed inspections will be independently tracked to ensure that a re-inspection takes place within 30 days, and management will review reports of all failed inspections, at least weekly. Finally, the Inspections Supervisor will receive more training on the Authority’s abatement policies, so that units that fail and are not corrected within the corrective period are abated according to the Authority’s HCV Administrative Plan.

View Audit 7520

Finding 5514 (2023-002)

Significant Deficiency 2023

Certell, INC

IN

Student Financial Aid Eligibility Significant Deficiency

A. The specific findings and plans of action are as follows: Huntington Junior College is committed to addressing the findings of our administration of Title IV programs. We concur with the findings and recommendations of the audit team. B. Actions Taken or Planned. Finding 2023-002 Failure to Meet...

A. The specific findings and plans of action are as follows: Huntington Junior College is committed to addressing the findings of our administration of Title IV programs. We concur with the findings and recommendations of the audit team. B. Actions Taken or Planned. Finding 2023-002 Failure to Meet the Standards for Safeguarding Customer Information. The security of all customer information is very important to Huntington Junior College. We have engaged a new IT firm to establish and maintain proper GLBA requirements. All faculty and staff will be retrained on information security policies and procedures.

View Audit 7272

Corrective Action Plans

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