Corrective Action Plans

Finding 24574 (2022-049)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using E...

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using ESV are based on tasks authorized and completed, and compared to approved authorizations before payment is issued. Also, individual caregiver verifications currently in ESV and Paper Service Verification (PSV) will be replaced with Electronic Visit Verification (EVV), which will help ensure payments are reflective of the services provided. MDHHS will continue to manually review PSVs until EVV is implemented. Anticipated Completion Date December 2024 Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24573 (2022-048)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is no...

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is now pulling reports by billing date instead of hospitalization dates to capture inpatient stays that are billed late. MDHHS also implemented a new policy on February 1, 2023, that allows payment for Home Help Program (HHP) services on the day an individual is admitted to the hospital. MDHHS changed the HHP payment process to an automated process during April 2022, tying payments to services on the Electronic Service Verification (ESV) prior to payment being made. In addition, MDHHS modified policy to begin recoupment by task instead of by daily rate for services provided on overlapping days. MDHHS provided a recoupment calculator and training for HHP staff to ensure the correct amount is recouped using the revised policy and procedure. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24572 (2022-047)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-047 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger ...

Finding 2022-047 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger updates to CHAMPS. MDHHS is also developing a prior report review process to ensure impacted records that do not get corrected with the CHAMPS retrigger are addressed. Anticipated Completion Date The system solution was implemented as of August 31, 2022. The prior report review process will be implemented by September 30, 2023, and reviews will be ongoing. Responsible Individual(s) Jamy Hengesbach, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24565 (2022-019)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Eligibility Material Weakness § 200.516

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other s...

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. MDHHS conducts mandated training for local office caseworkers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end of the PHE, as allowed by the Centers for Medicare and Medicaid Services. Anticipated Completion Date MDHHS continues to pursue other data sources for income verification and other system enhancements, in addition to determining where training is needed, on an ongoing basis. MDHHS expects to have all existing cases updated by June 2024. Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

View Audit 20093 Questioned Costs: $1

Finding 24510 (2022-046)

Significant Deficiency 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.516

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has ...

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has updated its internal policies to clarify how it manages workflow operations, while ensuring CCLB meets federal compliance requirements. In June 2022, the Child Care Organizations Act was amended and the language in Michigan Compiled Law 722.113h was changed to allow for inspections to be conducted in accordance with the State plan. The State plan specifies the annual licensing inspection requirement, at 45 CFR 98.42(b)(2)(i)(B) for unannounced inspections, must be performed ?not less than annually.? According to guidance from the Federal Office of Child Care Region V, this does not mean that inspections must be performed at exact 12-month intervals; therefore, the lead agency has flexibility to schedule the inspections within each calendar year. CCLB has subsequently completed the annually required renewal and/or interim inspections for the licenses identified in the audit sample. The applicable health and safety requirements were reviewed during the inspections conducted. For part b., CCLB is currently creating a new licensing system that will automate letters being sent to licensed child care providers. The new system will generate and store inspection reports directly in the system instead of creating the report in a separate location and then manually moving it to other locations (network drive, SharePoint). This allows the inspection reports to be maintained digitally and be accessible at a later date, while ensuring proper documentation to support renewal inspections is maintained. For part c., in June 2022, CCLB implemented a new process to save all extension letters mailed in PDF format and stored in the current system to be accessed and available upon request. In addition, CCLB will incorporate refresher trainings regarding documentation and storage of inspection reports at its biannual all-staff trainings. The current process of documentation creation and storage will be phased out after the new licensing system is implemented and processes are no longer manually done by CCLB staff. Anticipated Completion Date a. Completed b. October 1, 2023 c. October 1, 2023 Responsible Individual(s) Emily Laidlaw, LARA Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24508 (2022-044)

Material Weakness 2022

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking § 200.516

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE ...

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE policies and processes. ESA will inform the local office and BSC staff of policy changes or noted trends during PAO?s Bridges Bits and Bytes communications sessions. ESA?s Payment Accuracy Unit completed case reads in December 2022 and, as a result, ESA and MDE finalized a checklist on May 9, 2023, for use by local office staff to help ensure required documentation that supports eligibility is obtained. Also, MDE launched a Child Development and Care case review SharePoint site on May 1, 2023, to share information with MDE and MDHHS staff, reduce errors and promote integrity efforts for the program. Anticipated Completion Date MDHHS assistance and guidance for local office and BSC staff is ongoing. Responsible Individual(s) Mariah Schaefer, MDHHS Gayle Vail, MDHHS Lisa Brewer-Walraven, MDE

View Audit 20093 Questioned Costs: $1

Finding 24488 (2022-043)

Significant Deficiency 2022

State of Michigan

MI

Matching / Level of Effort / Earmarking Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2022-043 Aging Cluster, ALN 93.044, 93.045, and 93.053 - AIS FIRST User Access Management Views Although MDHHS thoroughly reviewed the access forms, MDHHS agrees that the final approval was not documented. Planned Corrective Action MDHHS has instructed staff that all forms must either cont...

Finding 2022-043 Aging Cluster, ALN 93.044, 93.045, and 93.053 - AIS FIRST User Access Management Views Although MDHHS thoroughly reviewed the access forms, MDHHS agrees that the final approval was not documented. Planned Corrective Action MDHHS has instructed staff that all forms must either contain a handwritten or electronic signature. MDHHS will also develop and implement an internal process for staff to ensure all future security forms contain the required approvals. Anticipated Completion Date July 1, 2023 Responsible Individual(s) Jen Hunt, MDHHS Cindy Masterson, MDHHS

View Audit 20093

Finding 24467 (2022-001)

Significant Deficiency 2022

University of the Pacific

CA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Finding #2022-001: Pacific understands finding #2022-001 and we agree that the University will modify internal controls to ensure accurate and timely reporting of student status changes to the National Student Loan Data System (NSLDS). The University has adjusted the completion/graduation process an...

Finding #2022-001: Pacific understands finding #2022-001 and we agree that the University will modify internal controls to ensure accurate and timely reporting of student status changes to the National Student Loan Data System (NSLDS). The University has adjusted the completion/graduation process and procedure to capture students (within the 60 days required to transmit status change to NSLDS) whose degree have been awarded. The university will correct error reports within the 10-day period to ensure the student status is updated within the 60-day requirement to transmit status change to NSLDS. Finding #2022-001 Action: The Office of the Registrar concurs with the audit test work of enrollment reporting which noted while there is a process in place to correctly submit information to NSLDS, during the audit test work the engagement team noted that three student's information was inaccurately reported to NSLDS. The University's control failed in detecting that inaccurate information was reported to NSLDS. It was discovered in December 2022 that the Registrar staff did not review the error report from the clearinghouse to ensure students? final status to NSLDS during the required reporting period. Per the 2022 Enrollment Reporting Guide, ?After the institution submits the Enrollment Reporting roster to NSLDS, NSLDS evaluates the enrollment Reporting roster and provides the institution an Error/Acknowledgement file. If errors are identified, institutions have 10 days to correct the errors and resubmit to NSLDS.? While the University acknowledges the critical nature of taking corrective action on this finding, it also notes incorrect reporting of ?G ? for ?W? statuses results in no harm to individual students in their loan repayment start dates nor financial loss to the U.S. Department of Education?s federal loan program. The University agrees with this statement and, as of July 2022, has adjusted the completion/graduation process and procedure to capture students (within the 60 days required to transmit status change to NSLDS) who have been awarded their degree but files appear in the clearinghouse error report. The University will correct error report and resubmit within 10-days and ensure in NSLDS that the update is complete. Person(s) responsible: Karen Johnson University Registrar

View Audit 22556

Finding 24397 (2022-002)

Material Weakness 2022

Ocala Housing Authority

FL

HUD Housing Programs Eligibility Material Weakness

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency ...

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency in Internal Control over Compliance). Originally reported as finding 2019-001 from September 30, 2019 (Material Weakness in Internal Control and Material Noncompliance) Statement of Condition: Out of a total tenant population of approximately 1,114 vouchers, 25 files were selected for testing. Exceptions were noted as follows: ? 1 tenant file had the following errors: o The tenant?s annual recertification application is missing. o The tenant?s signed 9886 form is missing. o The wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting this error would cause the HAP rent to increase by $9. o The tenant?s signed HAP contract is missing. ? 1 tenant file had the following errors: o The name and social security number for one of the tenant?s dependents was reported incorrectly on the 50058 form. o The tenant?s utility allowance was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would cause the HAP rent to increase by $56. ? 1 tenant file had the following errors: o The lease agreement was not signed by the tenant. o The tenant?s assets was reported in error. Correcting this error would cause the rent to increase by $8. ? 2 tenant files where the tenants? income was miscalculated. Correcting the errors would cause the HAP rent for one of tenant files to decrease by $12 and the other to increase by $181. ? 2 tenant files where the wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting these errors would cause the HAP rent for one of the tenant files to decrease by $13 and the other to increase by $14. ? 1 tenant file where the family?s assets was reported in error. Correcting the errors had no effect on the HAP rent. ? 1 tenant file where a member of the household moved but was reported on the 50058 form. ? 1 tenant file where the tenant?s signed HAP contract is missing. ? 1 tenant file where the EIV report was never generated or was misplaced. In addition to the above, we noted the following during our new admissions testing (out of a total of 118 new admission, 18 files were selected for testing.): ? 1 tenant file where the member of the household did not checkmark the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen or permanent resident. However, the member?s birth certificate confirms that the member is a U.S. Citizen. ? 1 tenant file where the tenant?s signed 214-affidavit is missing. However, the member?s birth certificate confirms that the member is a U.S. Citizen. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested will have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an Other Adult packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant?s file. The Counselor?s caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors? strength and weaknesses, and to determine if additional training and/or monitoring is needed. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor?s processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV staff will attend Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training. Effective Date: June 20, 2023 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636

View Audit 22927

Finding 24396 (2022-001)

Significant Deficiency 2022

The Reed Institute

OR

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The following corrective measures have been implemented: The Director of Financial Aid requests the amounts and number of students who received HEERF funding from the Business Office at the end of each quarter and reviews, confirms, and documents the date of request and review. A log of the website ...

The following corrective measures have been implemented: The Director of Financial Aid requests the amounts and number of students who received HEERF funding from the Business Office at the end of each quarter and reviews, confirms, and documents the date of request and review. A log of the website updates is maintained to document timely submission of data. The website was revamped to include all necessary reporting requirements including the number of eligible students for CRSSA HEERF II and ARP HEERF III. This updated process was implemented upon identification of the prior year finding, which occurred after the first quarterly report for fiscal year 2022 was posted.

View Audit 22802

Finding 24324 (2022-001)

Material Weakness 2022

Columbia Local School District

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring

The District is aware of the requirement in Federal Program legislation to ensure the inclusion of the prevailing wage rate provision in agreements, as well as to obtain certified payroll reports to verify prevailing wages were paid. At the time the District entered into the agreement with West Roo...

The District is aware of the requirement in Federal Program legislation to ensure the inclusion of the prevailing wage rate provision in agreements, as well as to obtain certified payroll reports to verify prevailing wages were paid. At the time the District entered into the agreement with West Roofing to install and renovate the HVAC system at Columbia High School, which was January 7, 2021, ESSER funds were not awarded to the District planned on using Permanent Improvement funds (a non-federal program sourced fund) to pay West Roofing. The District initially paid West Roofing from the Permanent Improvement fund for the installation/renovation of the HVAC at Columbia High School as per the initial contract. Once the ESSER funds were awarded, they allowed for previous expenses related to improving air quality to be included as part of reimbursement through ESSER funds. The prevailing wage was not met under the existing contract. The District has implemented the following Action Plan for Correction: 1. The Treasurer will ensure all agreements intended to be sourced through Federal Funds will contain prevailing wage rate provisions prior to signing such agreements. 2. The Treasurer will ensure that invoices from contractors contain the necessary prevailing wage certified payroll reports prior to approving such invoices for payment from Federal Funds. 3. The Treasurer will educate all responsible parties in the District regarding prevailing wage documentation to ensure appropriate documentation is obtained prior to payment to the contractors and prior to requesting Federal Funds.

View Audit 19658

Finding 24310 (2022-004)

Material Weakness 2022

West Noble School Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2022-004 Contact Person Responsible for Corrective Action: Barbara Fought Contact Phone Number: 260-260-3191 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: West Noble School Corporation will work with the Northeast Indiana Special Education ...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Barbara Fought Contact Phone Number: 260-260-3191 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: West Noble School Corporation will work with the Northeast Indiana Special Education Cooperative to implement the procedures detailed below. The Northeast Indiana Special Education Cooperative (NEISEC) Treasurer will reach out to member schools during the writing process of the IDEA 611 and 619 grants in order for each member school to submit their plans for their allocation of proportionate share money. NEISEC will provide the allocation amounts to each cooperative school. These submissions will include a proportionate share budget and include proportionate share staff names and any necessary information for the budget categories. The NEISEC Treasurer will then compile the proportionate share information and include on the grant submission. The LEA Treasurer will be given a copy of the grant application and budget upon approval of the grant. Any NEISEC employee being paid out of proportionate share grant funds for salary and benefits will be paid from the fiscal agent?s financial software. The LEA Treasurer will keep a spreadsheet of employee proportionate share expenses and this spreadsheet will be updated monthly based on time and effort logs that are submitted by all cooperative schools to the LEA and NEISEC. Any employee utilizing proportionate share funds that is not an employee of NEISEC, but rather a direct employee of a member school, will be paid directly by that member school. Time and effort logs will still be submitted to the LEA and NEISEC Treasurers for these employees in order to generate a direct reimbursement from the grant fund to the member school. For any expenses for a category outside of salary and benefits, a member school will need to submit an invoice and proof of purchase for equipment, supplies, etc. to NEISEC and the LEA in order to be directly reimbursed for those proportionate share expenses. If the request was not in the initial grant budget, the member school must submit all relevant information to NEISEC in order for a grant modification to be completed. Per IDOE the grant modification must be approved first prior to purchasing the items. Time and effort logs as well as invoice and proof of payment must be sent to the LEA Treasurer and NEISEC in order to complete the grant reimbursement requests. INDIANA STATE BOARD OF ACCOUNTS 29 TELEPHONE (260) 894-3191 - 5050 N US HIGHWAY 33 - LIGONIER, IN 46767-9606 - FAX (260) 894-3260 - 1-800-488-3191 - WNSC@WESTNOBLE.K12.IN.US At the end of the grant period, any school with remaining proportionate share money will be required to complete a waiver. As of this date (2/10/2023) DeKalb County Eastern CSD and NEISEC are still in communication with SBOA and IDOE to review the proportionate share plan and ensure all necessary requirements will be satisfied. Anticipated Completion Date: Changes discussed above will be implemented for the remainder of the FY23 grant period starting 07/01/2023.

View Audit 19951

Finding 24300 (2022-005)

Significant Deficiency 2022

City of Stockton

CA

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

2022-005 Reporting ? Internal Control and Compliance over Reporting City?s Corrective Action Plan: A recent appointment to the Debt and Treasury department has allowed for restructuring of the processes present within the department. Debt and Treasury personnel have been made aware of the previous ...

2022-005 Reporting ? Internal Control and Compliance over Reporting City?s Corrective Action Plan: A recent appointment to the Debt and Treasury department has allowed for restructuring of the processes present within the department. Debt and Treasury personnel have been made aware of the previous insufficiencies and will work with funding sources to identify which requirements are fulfilled by external project managers and which requirements need to be fulfilled by City staff. Responsible Person: Teri Chapa (Program Manager) Expected Implementation Date: March 2023

View Audit 19272

Finding 24243 (2022-001)

Significant Deficiency 2022

South Pike County School District

AR

Equipment & Real Property Management Matching / Level of Effort / Earmarking

The District ensures that starting 2022-2023 school year that all applicable construction contracts will contain the required notifications regarding compliance with the Davis-Bacon Act. Copies of the weekly certified payrolls will be obtained for the applicable projects. EDSD43522-001 The Distr...

The District ensures that starting 2022-2023 school year that all applicable construction contracts will contain the required notifications regarding compliance with the Davis-Bacon Act. Copies of the weekly certified payrolls will be obtained for the applicable projects. EDSD43522-001 The District paid a floor resurfacing company $202,775 to resurface floors throughout the district without obtaining a written contract that included the prevailing wage rate clause. Additionally, weekly certified payrolls were not submitted to the District. The superintendent and/or the district treasurer will ensure that all applicable construction contracts contain the required notification regarding compliance with the Davis-Bacon Act. Copies of the weekly certified payrolls will be obtained for the applicable projects. Met with contractor that is still working on our campus to finish the original project. He has turned in the weekly certified payrolls for the day in August 2022 that was worked and we have written contract on the exact amount that we will still owe to finish out the contract.

View Audit 20967

Finding 24240 (2022-001)

None 2022

Help Housing for the Disabled, Inc.

OH

Special Tests & Provisions Student Financial Aid Cash Management

RE: HELP HOUSING FOR THE DISABLED, INC. 26900 Euclid Avenue Euclid, Ohio 44132 SUBJECT: Corrective Action Plan 042EH430 HELP HOUSING FOR THE DISABLED Reporting Period Ending Date ? June 30, 2022 Finding 2022-001 CFDA: 14.157 Section 202 Direct Loan Criteria: Internal controls over compliance...

RE: HELP HOUSING FOR THE DISABLED, INC. 26900 Euclid Avenue Euclid, Ohio 44132 SUBJECT: Corrective Action Plan 042EH430 HELP HOUSING FOR THE DISABLED Reporting Period Ending Date ? June 30, 2022 Finding 2022-001 CFDA: 14.157 Section 202 Direct Loan Criteria: Internal controls over compliance should be in place to ensure the deposit of surplus cash amounts into the residual receipts account occurs within ninety days after year end. Condition: A deficiency in internal control over compliance existed due to the prior year excess surplus cash amount not being deposited into the residual receipts account within ninety days after the end of the annual fiscal period for which the surplus cash was calculated. Recommendation: The Project should establish procedures to ensure that surplus cash is deposited within ninety days after the end of the annual fiscal period for which the surplus cash is calculated. CORRECTIVE ACTION: Management has agreed to implement the process of depositing surplus cash on the day the audited financial statements are issued. Thorough review of financial statement notes and conversations with audit team during the review process will establish the amount of funds to be deposited. Once this internal review is complete and audited statements are issued the internal management team will routinely make the required deposit and follow up by providing payment confirmation to the outside audit team. This accountability confirmation process will ensure that the deposit is made timely and routinely. Any questions regarding this plan should be directed to: Belinda Glavic Grassi MA, CPA Chief Financial Officer Help Housing for the Disabled, Inc. (216) 432-4810

View Audit 20864

Finding 24207 (2022-004)

Material Weakness 2022

Gadsden County District School Board

FL

Questioned Costs Equipment & Real Property Management Procurement, Suspension & Debarment

The District will enhance inventory records and procedures to ensure that all property items are properly recorded in order to maintain accountability of items purchased with federal funds. Additionally, the District will consult with the grantor agency regarding the allowability of the questioned ...

The District will enhance inventory records and procedures to ensure that all property items are properly recorded in order to maintain accountability of items purchased with federal funds. Additionally, the District will consult with the grantor agency regarding the allowability of the questioned costs.

View Audit 21094 Questioned Costs: $1

Finding 24187 (2022-001)

Material Weakness 2022

St. Joseph's Center

PA

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

Finding 2022-001 Condition/Context The Center improperly calculated lost revenues as a result of improperly including contributions and improperly excluding contractual adjustments related to patient service revenues. This is not a statistically valid sample. Corrective Action Plan Corrective Action...

Finding 2022-001 Condition/Context The Center improperly calculated lost revenues as a result of improperly including contributions and improperly excluding contractual adjustments related to patient service revenues. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: St. Joseph's Center will correct the lost revenues calculation in the Period 4 Submission due March 31, 2023. In order to ensure that St. Joseph's Center properly calculates lost revenues in the future, all lost revenue calculations and source documents will be prepared by the Accounting Manager and reviewed by the Chief Financial Officer. Name(s) of Contact Person(s) Responsible for Corrective Action: James Ceccoli, CFO Anticipated Completion Date: 3/31/2023

View Audit 20800

Finding 24167 (2022-001)

Significant Deficiency 2022

Steel City Academy, Inc.

IN

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

The Executive Director, Managing Director of Operations, Finance Team and select board members will go through Federal Grants Training within the next 6 months. All contracts for construction projects will go through legal review before being signed by management. A contract checklist will be develo...

The Executive Director, Managing Director of Operations, Finance Team and select board members will go through Federal Grants Training within the next 6 months. All contracts for construction projects will go through legal review before being signed by management. A contract checklist will be developed to identify necessary provisions based on the funding source. This will be implemented immediately by the Executive Director and the Managing Director of Operations. The Board of Directors will approve all contracts over $15,000. Once the contract is implemented the Finance Team will ensure that all payroll documentation will be submitted in accordance with the cadence outlined in the contract.

View Audit 20234

Finding 24155 (2022-003)

None 2022

Bay Path University

MA

Student Financial Aid Matching / Level of Effort / Earmarking

Finding number: 2022-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: Upon review, the students identified in this finding did not appear on the Return to Title IV funds report ...

Finding number: 2022-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: Upon review, the students identified in this finding did not appear on the Return to Title IV funds report the Student Financial Services Office generates to identify and return unearned funds to the Department of Education. The University has updated procedures where a secondary report has been created and is evaluated on a weekly basis to ensure funds are returned in a timely manner. The University did not find any additional instances of this situation. Timeline for Implementation of Corrective Action Plan: Fiscal year 2023 Contact Person Stephanie King Executive Director of Student Financial Services

View Audit 21752

Finding 24154 (2022-002)

None 2022

Bay Path University

MA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding number: 2022-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: The University evaluated both student records to determine the cause for the late reporting to NSLDS. Th...

Finding number: 2022-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.063 and 84.268 Award year: 2022 Corrective Action Plan: The University evaluated both student records to determine the cause for the late reporting to NSLDS. The first student reported in this finding completed their degree requirements after the conclusion of the semester and the enrollment status reporting to the National Student Loan Clearinghouse. The policy of the University is to manually update NSLC however, the student was inadvertently missed in this process. The University office responsible for reporting enrollment status changes has determined this to be an isolated instance. The second student in this finding did not have their change in enrollment status updated in the early May reporting to NSLC as the student?s status did not change until two weeks later. The student?s record was rejected on the June NSLC report and not re-reported until the fall semester report. The office responsible for reporting enrollment status changes have updated their procedures to identify and review rejected student enrollment records. Rejected enrollment records will be evaluated by the reporting office and manually update NSLC with the accurate enrollment status to ensure proper updates are completed in a timely manner. Timeline for Implementation of Corrective Action Plan: Fiscal year 2023 Contact Person Stephanie King Executive Director of Student Financial Services

View Audit 21752

Finding 24119 (2022-008)

Material Weakness 2022

Universidad Teologica Del Caribe, Inc.

PR

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.334

Compliance requirement ? Earmarking Institutional Comments on Findings and Recommendations: 1. The institution does not concur with the auditor finding because all initiatives and expenditures related to the HEERF funds were precisely and strictly used to monitor, suppress the COVID-19 emergency and...

Compliance requirement ? Earmarking Institutional Comments on Findings and Recommendations: 1. The institution does not concur with the auditor finding because all initiatives and expenditures related to the HEERF funds were precisely and strictly used to monitor, suppress the COVID-19 emergency and additionally to outreach students about the opportunity to receive financial aid, (and they indeed received) due to recent unemployment and financial hardship during the pandemic times. Part of this initiatives were documented in our web page and disseminated through e-mails, phone calls, word of mouth among the community. The institution followed the recommended state and federal government guidelines on maintaining an active program to prevent and respond to the COVID-19 emergency. The institution uses HEERF funds to establish and maintain the following preventive and suppressing measures to fight the COVID-19 emergency, among others: a. Screening temperature b. Purchase covid test kits c. Created and posted many warning banners and instructions d. Purchase prevention and protection supplies for students, faculty, visitor and staff a. Hand sanitizer b. Alcohol auto sprayers c. Face Shields d. Thermometers e. Protective plastic shields for the desks e. Implemented remote education a. Habilitated smart educational rooms for remote education i. Smart TV's ii. High quality microphones iii. Acquired "Zoom" platform licenses iv. Laptops for remote education f. Provided student financial aid to support recent unemployment g. Provided counseling and psychology services to assist students to deal and recover from the emergency. h. Supported a clean and sanitary campus environment with hand sanitizers, handwashing stations, cleaning and disinfection. i. Implemented physical distance j. Keep continued communication with students k. Paid for time off to get vaccinated l. Provided sick leave for COVID treatment and to get vaccinated m. Procured additional space for remote education n. Support costs associated with remote education for students providing laptops and remote communication equipment and hardware Actions Taken or Planned: The institution understands that no further action is necessary or required.

View Audit 20027

Finding 24115 (2022-010)

Material Weakness 2022

Universidad Teologica Del Caribe, Inc.

PR

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

Compliance requirement ? Reporting Institutional Comments on Findings and Recommendations: 1. The institution does not concur with the auditor finding because the institution strictly followed and used the recommended HEERF methodology and reporting guidelines to prepare the quarterly and annual rep...

Compliance requirement ? Reporting Institutional Comments on Findings and Recommendations: 1. The institution does not concur with the auditor finding because the institution strictly followed and used the recommended HEERF methodology and reporting guidelines to prepare the quarterly and annual reports. Since the institution used the reimbursement method, the drawdown were the actual expenditures/costs incurred and requested for reimbursement. The HEERF reporting requirement does not make any indication nor reference to GAAP. The Institutional aid portion expenditures were supported by the proper invoice or check. The evidence was available to the auditors. 2. The institution concurs with the auditor finding. The institution inadvertently, did not include a line item from one of the quarterly reports. The period to make corrections was closed and we sent an e-mail to the department to amend this annual report. 3. The institution concurs with the auditor finding. The annual report contains detail statistical information that not necessarily is supported by our institutions data base and programs. As the ED expressed, this information was unique and challenging, and accordingly, the institution made some reasonable estimates and derivatives in the information provided. As you may notice in the referenced table by the auditor, the differences were minimal. 4. a. The institution concurs with the auditor finding on the difference in Item #5 of the quarterly report. The institution will accordingly amend the report. b. The institution does not concur with the auditor finding on the timely and accurate reporting in publicly posting the quarterly Student Aid Portion. The four quarterly reports were timely submitted with an e-mail to the HEERF reporting staff and timely posted in the institution web page as required by the HEERF reporting instructions. The reports were further reviewed by an officer of the Department of Education (ED). The ED expressed that this information may be unique and challenging to an audit, and indicated that for these public reporting requirements, the auditors may accept as evidence of compliance, contemporarily produced e-mails, webmaster logs, or other relevant documentation establishing good-faith indication that the institution posted the required information at approximately the timelines established by the public reporting requirements. Copy of the e-mails were available to the auditors as evidence of compliance. ED understands that this information may be unique and challenging to audit, particularly because auditors are asked to verify information posted on a webpage which may not be accessible during audit fieldwork. For these public reporting requirements, auditors may accept as evidence of compliance, contemporarily produced emails, webmaster logs, or other relevant documentation establishing a good-faith indication that the institution posted the required information at approximately the timelines established by the public reporting requirements (HEERF Grant Program Auditing Requirements, General Requirements and Information - All HEERF Grantees). 5. The institution does not concur with the auditor finding because the referenced payment was made in accordance with the Institution's fund distribution and the student financial needs, among other factors, at the time of the evaluation and distribution of the funds. The student financial circumstances may have change after the distribution and payments of the financial aid. Additionally, this is an immaterial amount as compare to the total amount of the funds distributed ant the quantity of students served (1 out of 460). Actions Taken or Planned: The institution understands that no further is needed or required.

View Audit 20027

Finding 24113 (2022-002)

Material Weakness 2022

Universidad Teologica Del Caribe, Inc.

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.302 § 200.303 § 200.305 § 200.317 § 200.318

1. The institution does not agree, nor concurs, with the auditors on this finding because the institution used the reimbursement payment method. This method was the preferred one when the non-federal entity, as our institution, cannot meet the requirements in 2 CFR, section 200.305(b)(1) for advance...

1. The institution does not agree, nor concurs, with the auditors on this finding because the institution used the reimbursement payment method. This method was the preferred one when the non-federal entity, as our institution, cannot meet the requirements in 2 CFR, section 200.305(b)(1) for advance payment and the federal awarding agency sets a specific condition for use of the reimbursement. Title 2 of the CFR Part 200.305(b)(1), establish among others: "The non-Federal entity must be paid in advance, provided it maintains or demonstrates the willingness to maintain both written procedures that minimize the time elapsing between the transfer of funds and disbursement by the non-Federal entity, and financial management systems that meet the standards for fund control and accountability as established in this part". Furthermore, 2 CFR Part 200.305(b)(3) states: "Reimbursement is the preferred method when the requirements in this paragraph (b) cannot be met, when the Federal awarding agency sets a specific condition per ? 200.208, or when the non-Federal entity requests payment by reimbursement. " Since our institution was not able to meet 2 CFR, section 200.305(b)(1), and the HEERF guidelines has specific condition on how to use the funds; we choose the reimbursement method in the execution of the funds. Our institution adopted all HEERF instructions and guidelines as their policies to comply with the HEERF requirements, in addition to the CFR's regulations. Below some of the guidelines, instructions ad FAQs we adopted followed" a. Higher Education Emergency Relief Fund III, Frequently Asked Questions, American Rescue Plan Act of 2021, Published May 11, 2021, Questions 7 and 11 updated May 24, 2021, Question 36 updated September 30, 2021 b. US Department of Education, Notice of Proposed Institutional Eligibility Criteria, February 25, 2021 c. Federal Register Notice of Interpretation (NOI), regarding Period of Allowable Expenses for Funds Administered under HEERF Program, March 22, 2021 d. HEERF Notice of Interpretation for Period of Allowable HEERF Expenses (March 22, 2021) e. HEERF Lost Revenue FAQs (March 19, 2021) f. HEERF Period of Allowable Expenses Grant Records Notice (March 19, 2021) g. HEERF Grant Program Auditing Requirements (March 8, 2021) h. CRRSAA HEERF II Section 314(a)(1) Frequently Asked Questions (Published January 14, 2021 and Updated: March 19, 2021) i. CRRSAA HEERF II Section 314(a)(2) Frequently Asked Questions (January 14, 2021) j. CRRSAA HEERF II Section 314(a)(4) Frequently Asked Questions (Published January 14, 2021 and Updated: March 19, 2021) k. HEERF I and HEERF II Comparison Fact Sheet (Published January 14, 2021 and Updated: March 19, 2021) 1. HEERF Lost Revenue FAQ's, Published March 19, 2021 m. HEERF II, Public and Private Nonprofit Institution (a)(2) Programs (CFDAs 84.425K), FAQ's, Published January 14, 2021 n. HEERF II, Proprietary Institution Grant Funds for Students (CFDA 84.425Q) ((a)(4) Program), FAQ's Published January 14, 2021, Updated March 19, 2021. o. HEERF II, Public and Private Nonprofit Institution (a)(1) Programs (CFDA 84.425E and 84.425F), FAQ's Published January 14, 2021, Updated March 19, 2021. p. CAREST Act HEERF Rollup FAQs (issued October 14, 2020 and revised November 20, 2020) q. CARES Act HEERF Round 3 FAQs (Issued October 14, 2020 and revised November 20, 2020) r. CARES Act HEERF Supplemental FAQs (Issued June 30, 2020 and revised September 08, 2020) s. CARES Act HEERF Student FAQ's (Issued May 15, 2020) t. CARES Act HEERF Institutional Portion under Section 18004(a)(1) and 18004(c) FAQ's, (Issued April 9, 2020) u. CARES Act HEERF Emergency Financial Aid Grants to Students under Section 18004(a)(1) and 18004(c) FAQ's, (Issued April 9, 2020) v. CARES Act HEERF Institutional Portion under Section 18004(a)(1) and 18004(c) FAQ's, Issued April 9, 2020 w. COVID-19 FAQ's for Title III, IV, V and VII Grantees, June 16, 2020 x. COVID-19 Letter to HEP Grantees on Flexibilities Available Under CARES Act Section 3518, July 1, 2020 2. The institution does not agree, nor concurs, with the auditors on this finding because, as we mention in number 1 above, the institution adopted and followed the federal award and HEERF guidelines in the execution of the funds. The HEER funds were provided during the special national emergency caused by COVID-19. The DOE and HEERF officials issued many written guidelines, instructions, and FAQ's (Frequently Asked Questions) documents, due to the nature and novel of the national emergency situation. The institution adopted, followed, and relied on the many referenced guidelines and exercise extreme judgment to ensure compliance with the federal requirements and use of the funds. The institution belief this referenced guidelines and instruction were very specific and sufficient to execute the use of the funds. All direct charges to federal awards were for allowable costs under the guidelines and instructions from the Department of Education. Some of the allowable costs were verified and validated by an officer of the Department of Education and reviewed by an independent consultant. 3. The institution concurs with the auditor finding. Actions Taken or Planned: The institution begins in addition to the adopted HEERF guidelines, instructions, and CFRs; to develop additional procurement policies and are in the process of completing those policies. The institution expects to have those completed by May 31, 2023.

View Audit 20027

Finding 24108 (2022-005)

Significant Deficiency 2022

Universidad Teologica Del Caribe, Inc.

PR

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Compliance requirement - Special tests and provisions ? Gramm-Leach Bliley Act- Student Information Security Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding. The Information Security Program Coordinator's functions were not specifie...

Compliance requirement - Special tests and provisions ? Gramm-Leach Bliley Act- Student Information Security Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding. The Information Security Program Coordinator's functions were not specified in a formal written contract, therefore, the consultant does not have a detail for the functions and responsibilities of his designation. (b) The institution agrees with the auditor on this finding. The Institution has yet to comply with, needs to terminate and correct some of the nine elements that are included in the FTC (Federal Trade Commission). Actions Taken or Planned: 1. A contract with the IT Program Coordinator is being finished with a breakdown of the responsibilities expected for the GLBA requirements. We should be starting it in May 2023. 2. There has been progress in the action plan where a set of estimated time of completion is provided. We will keep doing so and monitor every aspect of the risk assessment to cover and safeguard each area found with a document that indicates any advances. 3. The Institution with the IT Coordinator will keep monitoring each step for the progress and any delay with a task report where it will show any advance or delay for the pending findings so that we can track the development closely until finished. 4. Finally, we will continue with the efforts to document and complete the corrections to the risk assessment results.

View Audit 20027

Finding 24107 (2022-004)

Significant Deficiency 2022

Universidad Teologica Del Caribe, Inc.

PR

Student Financial Aid Special Tests & Provisions Eligibility

Compliance requirement - Special tests and provisions ? Enrollment Reporting Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding in that there was one (1) case where the information of enrollment of this student was not available for ex...

Compliance requirement - Special tests and provisions ? Enrollment Reporting Institutional Comments on Findings and Recommendations: (a) The institution agrees with the auditor on this finding in that there was one (1) case where the information of enrollment of this student was not available for examination. After multiples student search, the institution was unable to locate through the NSLDS the reported status update for said student. (b) The institution also agrees with the auditor in that there were (6) six cases where he noted that institution failed to report the student's status before the thirty (30) day deadline for the NSLDS web reporting. (c) The institution also agrees with the auditor in that there was one (1) instance where the institution submitted one (1) of its's enrollment report updates after the 15 days required timeline. Actions Taken or Planned: The institution would continue to submit its Enrollment Reports monthly in order to notify changes of student status to the Department of Education on a timely basis and to maintain the information of student's enrollment status more effectively.

View Audit 20027

Corrective Action Plans

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