Corrective Action Plans

Finding 522742 (2024-006)

Significant Deficiency 2024

Catholic Charities of the Diocese of Albany, INC

NY

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

At this time all fiscal standard and procedures are being updated. We will ensure documented policies exist and are being adhered to.

View Audit 342118

Finding 522702 (2024-001)

Significant Deficiency 2024

Webster University

MO

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

Webster University is in the midst of an enterprise system implementation, set to go live, June 2025, which will provide the institution with better tools with which to detect and update enrollment reporting discrepancies in a timely manner. Additionally, recently the enrollment reporting responsibi...

Webster University is in the midst of an enterprise system implementation, set to go live, June 2025, which will provide the institution with better tools with which to detect and update enrollment reporting discrepancies in a timely manner. Additionally, recently the enrollment reporting responsibilities have been transitioned to a more tenured member of the Registrar team, who is knowledgeable about enrollment reporting and understands its nuances and challenges and is positioned to be more successful in identifying and resolving discrepancies going forward. The Registrar’s Office, who is responsible for enrollment reporting, has also agreed to a system of monthly internal auditing processes so that there are more frequent and reliable checks to compare institutional data against NSLDS data for accuracy.

View Audit 342062

Finding 522687 (2024-001)

None 2024

McHenry County College

IL

Special Tests & Provisions Student Financial Aid Reporting

2024-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster – Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition Found During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV ...

2024-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster – Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition Found During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV Student Financial Aid for two out of twenty-five students tested until after 45 days when the student ceased attendance. We consider the untimely calculation and Return of Title IV Student Financial Aid to be an instance of noncompliance relating to the Special Tests and Provisions Compliance Requirement. Corrective Action Plan The Financial Aid Department has implemented a practice in which Return of Title IV funding will be performed, no later than the day prior to the weekly disbursement of funding to ensure accuracy while performing our awarding and disbursing processes. The practice includes a report creating a list of all students who require an evaluation on due to withdrawals from all Title IV eligible courses or grades of F in all courses or a combination of the two for an entire term. Upon report creation, the Director of Financial Aid will review all students accordingly and make a Return of Title IV calculation. This calculation will be reviewed by the Coordinator of Financial Aid to ensure accuracy and that a timely return has been completed. A document has been created that the Director of Financial Aid and the Coordinator of Financial Aid will Initial as they have completed their steps in the process. Responsible Person for Corrective Action Plan Financial Aid Director, Chris Heftka Coordinator of Financial Aid, Erik Mitchell Implementation Date of Corrective Action Plan October 1, 2024

View Audit 342022

Finding 522650 (2024-001)

Significant Deficiency 2024

Flathead Valley Community College

MT

Special Tests & Provisions Student Financial Aid Significant Deficiency

Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Numbers: P007A232416, Po33A232416, R063P232851, P268K242851 Program Name: Student Financial Aid Cluster Finding Summary: In the current fiscal year, the College failed...

Finding: 2024-01 Federal Agency Name: Department of Education Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Award Numbers: P007A232416, Po33A232416, R063P232851, P268K242851 Program Name: Student Financial Aid Cluster Finding Summary: In the current fiscal year, the College failed to initiate the notification process timely across 265 out of the 984 students (27%). The issue was discovered internally and corrected by the College, notifying those students during the fiscal year, however it was outside of the 30-day requirement. Corrective Action: The process has been reviewed and updated to correct this issue.  A task was implemented in PowerFAIDS that is assigned to the Student Financial Aid Director, and disbursement notifications will be emailed weekly.  If the email fails, a printed letter will be sent to the address on file.  A report was created and will be checked monthly to ensure all students have received notices. At this point, if the College determines someone did not receive the notification, the notification can be sent then and be in the 30-day regulation Responsible Individual: Crystal Morris, Director, Financial Aid Anticipated Completion Date: January 2025

View Audit 341896

Finding 522641 (2024-004)

Material Weakness 2024

Oak Park Elementary School District 97

IL

Questioned Costs Subrecipient Monitoring Eligibility § 200.516

Corrective Action Plan Finding No.: 2024 - 004 Condition: The District did not meet its maintenance of effort on either the aggregate or the per capita basis for fiscal year 2024. The shortfall in maintenance of effort was $401,982. Plan: The District will implement procedures and internal con...

Corrective Action Plan Finding No.: 2024 - 004 Condition: The District did not meet its maintenance of effort on either the aggregate or the per capita basis for fiscal year 2024. The shortfall in maintenance of effort was $401,982. Plan: The District will implement procedures and internal controls in FY 2025 to monitor maintenance of effort compliance. Furthermore the District will perform a comprehensive review of fiscal year 2024 expenditures to identify the cause of the decrease in special education expenditures from the FY 2023 amounts to determine if allowable exceptions can be identified in accordance with federal guidelines. Anticipated Date of Completion: 6/30/2025 Name of Contact Person: Sheila Johnson, Assistant Superintendent of Finance and Operations

View Audit 341891 Questioned Costs: $1

Finding 522637 (2024-001)

Material Weakness 2024

North Central Parke Community School Corporation

IN

School Nutrition Programs Eligibility Material Weakness § 200.303

FINDING 2024-001 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the...

FINDING 2024-001 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements for Eligibility related to income guidelines and Direct Certifications. No controls were in place to ensure the Food Service Director was inputting the income guidelines into the Harmony software correctly and that direct certification reports were run at the start of the school year and monthly thereafter, and that the student statuses were updated, accordingly. No one verified that the year-to-date direct certification reports were run to catch any students that were missing. Contact Person Responsible for Corrective Action: Vonessia Harmon, Business Manager Contact Phone Number and Email Address: 765-569-4195 harmonv@ncp.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director is responsible for ensuring the annual Free & Reduced income guidelines are entered into the student software system prior to Online Registration each school year. The Food Service Director will provide a copy of the income guidelines to the Business Manager for review. The Business Manager will review the income guidelines for accuracy and keep the documentation on file. The Food Service Director is responsible for running the Direct Certification reports. Direct Certification Reports shall be completed at the start of each school year and on a monthly basis thereafter. The Food Service Director is responsible for ensuring that student records are updated to the proper eligibility status in the student software system. The Business Manager is responsible for reviewing the Direct Certification Reports on a monthly basis and confirming that the student records have been updated. Audit Evidence: Copies of annual income guidelines and all Direct Certification Reports signed by both the Food Service Director and the Business Manager will be kept on file along with proof of the updated student record(s). Anticipated Completion Date: Effective immediately

View Audit 341884

Finding 522612 (2024-004)

Significant Deficiency 2024

Oklahoma State University

OK

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.308

OSU OKC and OSU Tulsa: The key personnel listed on the GAN will be responsible for completing the post-award training. Key personnel will also reconcile their federal grant budget on a monthly basis and a copy will be submitted to the Office of Institutional Grants and Compliance. The Director of ...

OSU OKC and OSU Tulsa: The key personnel listed on the GAN will be responsible for completing the post-award training. Key personnel will also reconcile their federal grant budget on a monthly basis and a copy will be submitted to the Office of Institutional Grants and Compliance. The Director of Grants and Compliance will verify the purchases using the approved grant budget. Signed time and effort reports will also be submitted to the grants office at this time. OSU IT: A new PI will be appointed to the grant and ensure accurate reporting of time and effort. OSU IT will also implement a comprehensive training program for PI and grant-related staff, establish a monitoring system to ensure ongoing compliance, and designate a compliance officer to oversee this process. Will also implement a digital tracking system to streamline the reporting process and reduce the risk of errors.

View Audit 341848

Finding 522609 (2024-003)

Significant Deficiency 2024

Oklahoma State University

OK

Matching / Level of Effort / Earmarking Student Financial Aid Reporting § 200.303

OSU CHS will have a second person verify the data entered into NSLDS and document that it has been verified.

View Audit 341848

Finding 522608 (2024-002)

Significant Deficiency 2024

Oklahoma State University

OK

Questioned Costs Student Financial Aid Significant Deficiency § 200.303

OSU OKC Financial Aid and Registrar worked together in December 2023 to develop a timeline for updating SOATBRK in Banner. This Banner screen records the number of days in a break that is used for the R2T4 calculation. In addition, the Registrar will reach out to Financial Aid at the time they are...

OSU OKC Financial Aid and Registrar worked together in December 2023 to develop a timeline for updating SOATBRK in Banner. This Banner screen records the number of days in a break that is used for the R2T4 calculation. In addition, the Registrar will reach out to Financial Aid at the time they are building terms for the next academic year. This will serve as a backup to ensure the process is not missed.

View Audit 341848 Questioned Costs: $1

Finding 522604 (2024-002)

Significant Deficiency 2024

Caldwell University

NJ

Special Tests & Provisions Student Financial Aid Reporting

Caldwell University's Office of Registrar will strictly comply with the enrollment reporting timeframes of the National Student Clearinghouse by partnering and communicating more closely with the Office of Financial Aid to make sure they are aware of all changes in student enrollment statuses in a t...

Caldwell University's Office of Registrar will strictly comply with the enrollment reporting timeframes of the National Student Clearinghouse by partnering and communicating more closely with the Office of Financial Aid to make sure they are aware of all changes in student enrollment statuses in a timely manner. In addition, the Office of the Registrar will review internal student coding to make sure it is accurate and properly reported.

View Audit 341845

Finding 522600 (2024-001)

Significant Deficiency 2024

Caldwell University

NJ

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

Starting with the 2024-25 program year, the Office has reinstated its standard for disbusrement reporting to COD, following the replacement of the dedicted Loan Coordinator. Disbursements will now be reported within 48 hours of the internal disbursement to the student account. ...

Starting with the 2024-25 program year, the Office has reinstated its standard for disbusrement reporting to COD, following the replacement of the dedicted Loan Coordinator. Disbursements will now be reported within 48 hours of the internal disbursement to the student account. Furthermore, the procedures for monthly fund reconciliation and disbursement monitoring will be rigorously followed to ensure compliance with federal regulations and to uphold Financial Aid Best Practices in awarding federal aid and managing funds.

View Audit 341845

Finding 522593 (2024-001)

Significant Deficiency 2024

University of Mobile, Inc.

AL

Eligibility Matching / Level of Effort / Earmarking

2024-001 Federal Direct Student Loans, ALN 84.268 Condition: There were incorrect cost of attendance amounts used to calculate subsidized loans for 5 out 40 students tested. Criteria: According to the U.S. Department of Education, an institution must use cost of attendance minus expected family co...

2024-001 Federal Direct Student Loans, ALN 84.268 Condition: There were incorrect cost of attendance amounts used to calculate subsidized loans for 5 out 40 students tested. Criteria: According to the U.S. Department of Education, an institution must use cost of attendance minus expected family contribution and other financial aid to calculate the amount of subsidized loans that students are eligible to receive. Cause: The University’s student information system (SIS) uses rules to determine which budget components should be assigned to students' cost of attendance based on housing choice, program of student, and classification. It was determined early in the packaging process that some of those budget components were being assigned incorrectly. A support ticket was opened with SIS helpdesk and the issue was corrected within 48 hours. Once the SIS was corrected to assign budget components according to the rules for each budget, all students were reassigned budgets to reflect the correct amounts. Effect: Subsidized loans could have been improperly calculated at the time of packaging, but prior to applying these funds to student charges, there are student eligibility criteria (SEC) rules in place that prevents aid from transmitting if the student is not entitled. In addition, staff weekly run reports to review cost of attendance and subsidized/unsubsidized eligibility. Context: During the compliance audit testing of federal direct student loans, it was determined that the incorrect cost of attendance total was used on the student loan worksheet to calculate eligibility for 5 out of 40 students tested, but SIS reflected the updated correct cost of attendance. Recommendation: We recommend the University continue to monitor the system for future issues and consider updating the supporting documentation as appropriate in the future. View of Responsible Officials and Planned Corrective Action: Management has corrected the SIS. In reviewing the students affected, it was determined the calculated subsidized loan amounts were still appropriate even though the student loan worksheet did not match the cost of attendance reflected in the SIS.

View Audit 341821

Finding 522589 (2024-001)

Significant Deficiency 2024

Town of Kennebunkport

ME

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Management’s response/corrective action plan: The Town acknowledges the finding and is taking steps to address the deficiency. Actions include implementing procedures to verify and document contractor eligibility. These measures will ensure contractors are not suspended or debarred, particularly for...

Management’s response/corrective action plan: The Town acknowledges the finding and is taking steps to address the deficiency. Actions include implementing procedures to verify and document contractor eligibility. These measures will ensure contractors are not suspended or debarred, particularly for federally funded projects. The Town is committed to maintaining compliance and protecting federal funding.

View Audit 341812

Finding 522513 (2024-002)

Significant Deficiency 2024

Shelton State Community College

AL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Personnel Responsible for Corrective Action Plan: Dr. Anika Lodree, Dean of Student Services Anticipated Completion Date: 02.28.2025* Corrective Action Plan: In receipt of these findings, the College intends to heavily scrutinize data files before submission and utilize all resources at its disposal...

Personnel Responsible for Corrective Action Plan: Dr. Anika Lodree, Dean of Student Services Anticipated Completion Date: 02.28.2025* Corrective Action Plan: In receipt of these findings, the College intends to heavily scrutinize data files before submission and utilize all resources at its disposal to obtain guidance on the correct method for submitting any similar future data files at the time of their occurrence and initial submission. * This is assuming that the Gainful Employment reporting is certified through the National Student Clearinghouse. Until the Gainful Employment report is certified, they have advised that no further changes may be submitted.

View Audit 341788

Finding 522512 (2024-004)

None 2024

Carthage Independent School District

TX

School Nutrition Programs Matching / Level of Effort / Earmarking

Action Taken: The district concurs with this finding. The staff of the district has been properly trained to use the Paid Lunch Equity (PLE) Tool provided by USDA to determine adequate price for paid lunches. The CFO will make the calculation annually and will take to the board any changes that need...

Action Taken: The district concurs with this finding. The staff of the district has been properly trained to use the Paid Lunch Equity (PLE) Tool provided by USDA to determine adequate price for paid lunches. The CFO will make the calculation annually and will take to the board any changes that need to be made to ensure compliance with TDA pricing regulations.

View Audit 341786

Finding 522492 (2024-003)

Material Weakness 2024

Westmoreland County Community College

PA

Questioned Costs Special Tests & Provisions Student Financial Aid

Finding 2024-003: Student Financial Aid Cluster Special Tests and Provisions - Return of Title IV Funds View of Responsible Officials and Planned Corrective Action: Challenges with the new SIS resulted in errors in calculations and the delay of the return of Title IV funds to the DOE. After Cases/Ti...

Finding 2024-003: Student Financial Aid Cluster Special Tests and Provisions - Return of Title IV Funds View of Responsible Officials and Planned Corrective Action: Challenges with the new SIS resulted in errors in calculations and the delay of the return of Title IV funds to the DOE. After Cases/Tickets were reported to the SIS the System is now calculating correctly based on system updates and the process of returning funds is working as expected. Human error was a factor in two of the instances noted. The College has implemented internal controls and another level of review of the Return to Title IV calculations and return process based on the functioning of the new SIS.

View Audit 341751 Questioned Costs: $1

Finding 522482 (2024-003)

Significant Deficiency 2024

Southwest Kansas Area Cooperative, District Number 613

KS

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

Finding 2024-003 Recommendations: The Director and the accounting department need to create procedures to ensure that both parties are reporting the same expenditures. Within the procedures created, there needs to be checks and balances to ensure that the recording is occurring before reporting figu...

Finding 2024-003 Recommendations: The Director and the accounting department need to create procedures to ensure that both parties are reporting the same expenditures. Within the procedures created, there needs to be checks and balances to ensure that the recording is occurring before reporting figures to the State. Action Taken: We agree with the recommendation. Our targeted implementation date is February 2025.

View Audit 341750 Questioned Costs: $1

Finding 522353 (2024-002)

Significant Deficiency 2024

Catskill Central School District

NY

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring

U.S. Department of Education Passed-Through Entity: New York State Department of Education Finding 2024-002 (Significant Deficiency) COVID-19 - Education Stabilization Fund: ARP Homeless II (Assistance Listing# 84.425U) ARP Leaming Loss (Assistance Listing# 84.425U) ESSER II (Assistance Listing# 84....

U.S. Department of Education Passed-Through Entity: New York State Department of Education Finding 2024-002 (Significant Deficiency) COVID-19 - Education Stabilization Fund: ARP Homeless II (Assistance Listing# 84.425U) ARP Leaming Loss (Assistance Listing# 84.425U) ESSER II (Assistance Listing# 84.425D) ARP Summer Enrichment (Assistance Listing# 84.425U) ARP Comprehensive After School (Assistance Listing# 84.425U) ARP ESSER III (Assistance Listing# 84.425U) Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Criteria - Expenditures must be used to prevent, prepare for, and respond to COVID-19. These programs are authorized, as applicable, by the Coronavirus Response and Relief Supplemental Appropriations (CRRSA) Act, 2021, Pub. L. No. 116-260 (December 27, 2020), and the American Rescue Plan (ARP) Act of 2021, Pub. L. No. 117-2 (March 11, 2021). The regulations in 34 CRF Part 76 (State Administration), 2 CFR Part 200 (Uniform Administrative Requirements, Cost Principles, and Audit Requirement for Federal Award and 31 CFR Part 205 (Cash Management Improvement Act) apply to these programs. The School District must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control Integrated Framework", issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statues, regulations, and the terms and conditions of the Federal awards. (c) Evaluate and monitor the non-Federal entity's compliance with statutes, regulations and the terms and conditions of Federal awards. ( d) Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings. (e) Take reasonable measures to safeguard protected personally identifiable information and other information the Federal awarding agency or pass-through entity designates as sensitive or the non-Federal entity considers sensitive consistent with applicable Federal, State, local and tribal laws regarding privacy and responsibility over confidentiality. Condition/Context - We haphazardly sampled five COVID-19 - Education Stabilization Fund (ESF) expenditures. Our audit procedures found one disbursement where management overrode documented internal control procedures. We viewed invoices, purchase orders, and payment support and noted the disbursement was processed and paid without proper documentation to support the payment made and the payment was processed without the internal claims auditor's review prior to payment. Cause - Management override of established controls. Effect - Revenues and expenditures for one of the ESF grants were overstated prior to adjustment. Adjustment resulted in recording a receivable from the vendor and an offsetting liability to the passthrough agency providing the grant funding. Questioned Costs - None. The improper payment was subsequently adjusted out of expenditures. Recommendation - We recommend that the School District ensures that only disbursements that have been processed and approved by the internal claims auditor to be paid. Management Response - School District management concurs with the finding and will take corrective action. Corrective Action - The Business Office will review and adhere to all cash disbursements procedures and protocols. Completion Date - Effective immediately. Respectfully Submitted, Dr. Brett Miller, Assistant Supt. for Business

View Audit 341608

Finding 522344 (2024-003)

Significant Deficiency 2024

Region One Education Service Center

TX

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

2024-003 Matching The GEAR UP program will update its review and approval process for in-kind documentation submitted by partners to ensure correct and accurate data is submitted in the annual grant close out process which includes the Annual Performance Report (APR) due to USDE in April 2025. Hourl...

2024-003 Matching The GEAR UP program will update its review and approval process for in-kind documentation submitted by partners to ensure correct and accurate data is submitted in the annual grant close out process which includes the Annual Performance Report (APR) due to USDE in April 2025. Hourly values for teachers and other professionals will be updated on an annual basis. The identified rate has been adjusted to ensure the correct rate is used during final submission of in-kind data for teacher hours in the APR. Proposed Completion Date: April 1, 2025 Name of contact person: Rumalda Ruiz, Deputy Director – Business, Operations, & School Finance Support Contact: (956) 984-6290

View Audit 341604

Finding 522305 (2024-002)

Significant Deficiency 2024

School District of the City of Hazel Park

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.303

See Corrective Action Plan for Chart/Table

View Audit 341580

Finding 522295 (2024-005)

Significant Deficiency 2024

Commonspirit Health

IL

Student Financial Aid Special Tests & Provisions Reporting § 200.303

REFERENCE: 2024-005 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College...

REFERENCE: 2024-005 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting. Student enrollment information, including enrollment status changes and campus level and program level information, was not reported accurately and/or timely to the NSLDS for certain students. Corrective Action Plan: Beginning Spring of 2024, Good Samaritan College changed their reporting cycle to include five submissions per semester. This change was encouraged as a best practice from the American Association of Collegiate Registrars and Admission Officers (AACRAO). Reporting five times within a traditional semester creates an approximate 30-day cycle from first submission to the next, keeping reporting to NSLDS well below the 60-day reporting minimum. Evidence of this will be shared in the College’s monthly Compliance Committee Meetings. To address the issues of reporting “less than half time” for students who were enrolled in zero hours, Good Samaritan College has contacted the Student Information System vendor, Ellucian, to identify a technological solution allowing the reporting of students with zero hours correctly. Until a technological solution can be found, the College Registrar will run a report to cross check against each enrollment transmission for National Student Clearinghouse identifying all students who drop to zero hours and report them as withdrawn to NSC. In turn, NSC will correctly report to NSLDS the status of withdrawn. Reporting is signed off and evidence of this will be shared in the College’s monthly Compliance Committee meetings. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Expected Completion: February 2025

View Audit 341568

Finding 522294 (2024-004)

Material Weakness 2024

Commonspirit Health

IL

Eligibility Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2024-004 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patie...

REFERENCE: 2024-004 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Bailey-Boushay House Administrative staff will send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor will forward a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor will discuss the status of these updates during meetings with care manager/social worker. Notes will be made on the caseload list to document the discussion of status. The Clinical Supervisor will send a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note will be provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations will be retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Expected Completion: February 2025

View Audit 341568

Finding 522293 (2024-003)

Significant Deficiency 2024

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

REFERENCE: 2024-003 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did no...

REFERENCE: 2024-003 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did not calculate and return Title IV funds in a timely manner to the U.S. Department of Education, within 45 days after the date the institution determined that a student withdrew. Good Samaritan College of Nursing & Health Science did not provide evidence of an effective review process to ensure the timely calculation and return of Title IV funds to the U.S. Department of Education. Corrective Action Plan: Beginning in April 2024, Financial Aid Services incorporated an additional step to the return disbursement process to ensure timely returns. The additional step occurs after each return to ensure the Common Origination and Disbursement (COD) system shows the return successfully processed for the student. Financial Aid Services reviews the student’s disbursement detail history in COD to confirm the return credit adjustment has been applied to the appropriate record and it shows an applied date at ED within the appropriate timeframe for the return. To document this process has been completed, Financial Aid Services maintains a spreadsheet for all returns. The spreadsheet documents the student, amount of the return, date processed in Financial Aid and Student Accounts, date processed in G5, and date applied at ED per COD. If any issues arise during this review where the return did not successfully apply at ED, Financial Aid Services reviews and resolves rejects immediately so the record can move forward and process successfully within the required timeframe. The Dean of Financial Services validates the report submitted by Financial Aid Services on a monthly basis and submits the document to the President. Both review and sign the documentation. This documentation is presented to the GSC Compliance Oversight Committee to ensure monthly verification of time return of Title IV funds. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Completion: April 2024

View Audit 341568

Finding 522208 (2024-001)

Significant Deficiency 2024

Hibiscus Childrens Center, Inc.

FL

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

Staff at Hibiscus Children's Center are required to complete training curriculums on an annual basis. All Full-Time staff that work directly with children, supervisors and directors must complete a minimum of 40 hours of training annually. All Part-Time staff that work directly with children must ...

Staff at Hibiscus Children's Center are required to complete training curriculums on an annual basis. All Full-Time staff that work directly with children, supervisors and directors must complete a minimum of 40 hours of training annually. All Part-Time staff that work directly with children must complete a minimum of 20 hours of training annually. Program Directors and Supervisors are responsible to monitor their staff to ensure that they successfully complete their annual training requirements. The Program Directors will compile information for each of their staff that identifies the required training, and the dates that they successfully completed each training session. The Program Directors will be responsible for collecting the training certificates and submitting them to Human Resources so they can be placed in the individual personnel files. To better manage the completion and tracking of the required trainings, staff will be required to complete their designated training requirements during the period of July 1 to December 31st. This will allow for the trainings to be logged in time for our annual re-licensing and audits. If the staff do not meet the required training hours, and/or do not meet the required time frame, the Program Directors will take necessary action to ensure compliance and appropriate disciplinary measures.

View Audit 341419

Finding 522160 (2024-002)

Material Weakness 2024

Community Crisis Services and Food Bank

IA

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303

Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the Organization document review of all billings Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CommUnity...

Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the Organization document review of all billings Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CommUnity has recently hired a Chief Financial Officer (CFO), which will provide an additional layer of financial approval and review. Finance Director will complete billings and CFO will review for accuracy each month, which will provide for additional oversight. Name(s) of the contact person(s) responsible for corrective action: Jennifer Steines and Angie Meiers Planned completion date for corrective action plan: February 2025

View Audit 341375

Corrective Action Plans

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