Corrective Action Plans

Finding 549905 (2024-018)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.302 § 200.430

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance r...

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance review of compensation costs charged to federal sponsors. Huron Consulting routinely works with Carnegie R1 institutions to review research compliance issues. Huron conducted a detailed review of an extensive data set for ESC payments made to USU employees, focusing on employees who had salary charged to federal grants or designated as a grant cost share. This review identified limited instances (1) when salaries directly charged to sponsored projects included extra service compensation in the institutional base salary and (2) when extra service compensation was charged to federal sponsors. Overall, the review found that the vast majority of USU ESC payments (referred to as secondary payments in the internal audit) were not charged to federal sponsored awards. Out of a total population of $5.8 million ESC payments reviewed, the unallowed compensation costs related to ESC is approximately $140,000. USU is in the process of addressing the unallowable compensation costs by removing unallowable charges on open awards and refunding unallowable charges on closed awards. 2) Policies and required documentation for ESC. ESC Policies: USU is reviewing its policies associated with ESC and institutional base salary (IBS) (both currently defined in USU Policy 376: Extra Service Compensation). A working group has been established that includes the Provost’s Office, the President’s Office, the Office of Research and Human Resources to develop updated procedures for requesting ESC. Once in place, a new Extra Service Compensation website will be rolled out that will provide guidance on the policy, acceptable uses of extra-service Compensation, and training materials. In conjunction with the website development, a communication plan to inform stakeholders, especially approving department heads and administrators, will be developed. Institutional Base Salary Policy and Procedures: USU will create and implement an Institutional Base Salary policy that aligns with federal requirements and industry best practices and specifically defines salary components and the associated pay codes that are included and excluded from an employee’s institutional base salary. USU will also update its time and effort certification system with correct institutional base salary mapping. 3) Internal controls for sponsored program compensation USU will implement the following improvements in its internal controls: Revised ESC Form. USU has revised its ESC Form to include documentation / calculation demonstrating payment is commensurate with institutional base salary. Revised ESC Application and Approval Process: USU has already updated the internal ESC review process to include appropriate controls to ensure that all ESC requests are reviewed for Uniform Guidance and USU policy requirements. In this regard, all ESC requests at USU are now reviewed by the Office of Sponsored Programs in the context of all funding sources associated with the applicant (including cost share indexes). This change directly addresses prior routing based on the source of funding which resulted in the Office of Research/Sponsored Programs being bypassed for state-funded ESC requests. Certification language has been inserted at appropriate approval levels to ensure that employees are not receiving ESC related to their primary position/workload. Improved Definitions of Primary Work Statement: USU has initiated a collaborative effort between Human Resources, the Provost’s Office, and the Office of Research to clearly define the primary work assignment for faculty via the role statement or annual work plans to clarify the full workload associated with the IBS. Increased Compliance Monitoring: After-the-fact monthly review of ESC payments is being collaboratively performed between the Office of Research and Provost’s Office. Additionally, USU has reorganized its operations to house post-award research administrators within the Office of Research and added an additional supervisory position to manage post award compliance and management. USU will charge central-post award research administrators with monitoring salary charges to sponsored awards and cost share accounts as a secondary internal control. Research Incentive Programs: The Office of Research will establish permissible conditions and components for research incentive programs and any and all proposed programs will be reviewed and approved by the Office of Research before implementation. 4) Adequate training to university personnel regarding sponsored programs compensation compliance. Uniform Guidance training for faculty and staff: USU is building and incorporating new training modules for those managing federal awards which will include guidance on allowable compensation costs and determining institutional base salary. ESC Training: USU has developed a new required annual training for anyone requesting or approving ESC from all types of funding sources at USU (delivered via USU’s Learn Blue system). This training addresses requirements for ESC and employees’ role and responsibilities for compliance requirements. Additional training regarding time and effort certification will be developed. Pay Code Training: USU will provide additional training and education for departmental and payroll staff responsible for coding and processing salary across the institution. Responsible Person: Lisa M. Berreau Vice President for Research Utah State University 435-797-3509 Anticipated completion date of corrective action plan: Actively in progress and full completion by Jan. 1, 2026.

View Audit 352012

Finding 548761 (2024-008)

Significant Deficiency 2024

State of Utah

UT

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of ...

2024-008. Non-Payroll Expenditures Did Not Receive Adequate Reviews State Agency: University of Utah Research & Development Federal Agency: Department of Health and Human Services The Controller’s Office will work directly with the identified PI’s to provide additional training and understanding of the importance of appropriate and timely approvals. In addition, the Controller will work with the Office of Sponsored Projects and the Financial Reporting & Accounting office to review current training processes, as well as the process for notification and follow up with those AE’s/PI’s who do not meet the standard set forth in policy. Contact Person: Steven Phillips Anticipated Correction Date: 6/30/2025

View Audit 352012

Finding 548751 (2024-011)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency

2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and p...

2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

View Audit 352012

Finding 548749 (2024-010)

Significant Deficiency 2024

State of Utah

UT

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

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a r...

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

View Audit 352012

Finding 548698 (2024-015)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative s...

2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative so we have updated the current report to reflect the accurate household counts with an AMI under 100%. Anticipated correction date: March 31, 2025 Responsible person: Ambra Peterson, HCD Program Manager, 385-312-6551

View Audit 352012

Finding 548694 (2024-009)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took ap...

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712

View Audit 352012 Questioned Costs: $1

Finding 548693 (2024-007)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applic...

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applicable period of performance in which the work was performed, and expenses were incurred and will ensure that costs are subsequently charged to the corresponding grant award. Anticipated correction date: January 31, 2025 Responsible person: Nathan Harrison, Executive Finance Director, 801-808-0676

View Audit 352012 Questioned Costs: $1

Finding 548686 (2024-005)

Significant Deficiency 2024

Wilberforce University

OH

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

Management agrees with the auditors and has initiated the necessary corrective action plan to mitigate the deficiency from occuring again. The plan is to implement new procedures to ensure the reporting to the NSLDS is done on a timely basis.

View Audit 352009

Finding 548676 (2024-004)

Significant Deficiency 2024

Stevenson University, Inc.

MD

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

Name of Responsible Individual: Brandon Rhone, Analyst, Financial Aid Systems, and Chad Wick, Director Financial Aid Corrective Action: The Vice President of Enrollment created a process, implemented in the Spring of 2023, that automated the student loan disbursement notifications with-in the requi...

Name of Responsible Individual: Brandon Rhone, Analyst, Financial Aid Systems, and Chad Wick, Director Financial Aid Corrective Action: The Vice President of Enrollment created a process, implemented in the Spring of 2023, that automated the student loan disbursement notifications with-in the required 30 days of student accounts transmitting their loans, but some of them were already disbursed before this new process. To further enhance this process the FA Analyst created a process in Colleague to automate this process as well as allow for us to keep better records of the notifications. This new process was implemented in 2024, and the University should see results on the 2024-2025 Audit. Anticipated Completion Date: March 31, 2025

View Audit 351998

Finding 548673 (2024-005)

Significant Deficiency 2024

Stevenson University, Inc.

MD

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Name of Responsible Individual: Montague Blount, Registrar Corrective Action: The University Registrar has worked to develop and implement a plan to ensure appropriate cross-training, position backup, and a system of proper checks and balances to improve quality control and continuity in executing ...

Name of Responsible Individual: Montague Blount, Registrar Corrective Action: The University Registrar has worked to develop and implement a plan to ensure appropriate cross-training, position backup, and a system of proper checks and balances to improve quality control and continuity in executing core functions within the Registrar's Office. To enhance our efforts on this front, the University Registrar will implement additional training measures and reporting SOPs to ensure all status changes and error records are submitted to the NSC/NSLDS website within the required timeframe. These efforts will strengthen accuracy and overall compliance with reporting requirements. Enrollment reporting remains a critical focus of this initiative. Anticipated Completion Date: June 30, 2025

View Audit 351998

Finding 548666 (2024-006)

Significant Deficiency 2024

Stevenson University, Inc.

MD

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Name of Responsible Individual: Chad Wick, Director Financial Aid Corrective Action: During the 2024 fiscal year, the Financial Aid office experienced several staffing changes, including hiring a new Director of Financial Aid. The newly hired staff did not receive the proper training to perform th...

Name of Responsible Individual: Chad Wick, Director Financial Aid Corrective Action: During the 2024 fiscal year, the Financial Aid office experienced several staffing changes, including hiring a new Director of Financial Aid. The newly hired staff did not receive the proper training to perform their roles effectively. This led to errors identifying and calculating the unearned amount of Title IV assistance to be returned. The previous Financial Aid Director was terminated before the prior corrective action plan could be fully completed. New leadership, in collaboration with the Office of Information Technology, developed an automated weekly report confirming student withdrawal dates for the 24-25 academic year. The report is emailed to Financial Aid director every Friday. The Financial Aid Director reviews the report and identifies Title IV recipients. The return of Title IV funds calculation is performed for those students. Any funds required to be disbursed or returned are then processed. Anticipated Completion Date: March 31, 2025

View Audit 351998

Finding 548665 (2024-002)

Significant Deficiency 2024

Stevenson University, Inc.

MD

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

Name of Responsible Individual: Brian Emery, Associate Director Financial Aid and Chad Wick, Director Financial Aid Corrective Action: During the 2024 fiscal year, the Financial Aid office experienced several staffing changes, including hiring a new Director Financial of Aid. They also contracted w...

Name of Responsible Individual: Brian Emery, Associate Director Financial Aid and Chad Wick, Director Financial Aid Corrective Action: During the 2024 fiscal year, the Financial Aid office experienced several staffing changes, including hiring a new Director Financial of Aid. They also contracted with a third-party servicer that assisted with the verification process. The newly hired staff did not receive the proper training to perform their roles effectively. These two changes led to errors in verifying certain data when performing verification. The Financial Aid office implemented a Quality Assurance two-step verification process, but this took place after some of the 23-24 awards were processed. The Financial Aid office will run a report to identify all students selected for verification for 2024-2025 and review them for accuracy. If any corrections are needed, they will be updated, and awards will be adjusted as needed. Anticipated Completion Date: March 31, 2025

View Audit 351998

Finding 548660 (2024-002)

Significant Deficiency 2024

Food Lifeline

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and t...

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and the total revenues earned under each award to ensure the amounts are consistent with those reported in the schedule of expenditures of federal awards. Anticipated Completion Date: June 30, 2025

View Audit 351990

Finding 548648 (2024-002)

Significant Deficiency 2024

Queens University of Charlotte

NC

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

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the students i...

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the students in question; however, we can only document the loan disbursement notification was sent but are unable to document the date or content of the communication. Students identified with missing communications are from spring 2024. Our internal processes dictate that the notification would normally be sent on the date of disbursement. We will develop and implement a loan disbursement notification to loan recipient reconciliation process to effectively capture students with missing communications to ensure that both a record of the notification and the date are maintained. Anticipated Completion Date: August 15, 2025

View Audit 351979

Finding 548645 (2024-001)

None 2024

Queens University of Charlotte

NC

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Individual Responsible for Corrective Action: Debbie Gannon, Registrar Corrective Action: Certain students’ campus-level enrollment data was not accurately reported. The Registrar’s Office will determine why certain students falling outside of normal graduate submission schedules are not being cap...

Individual Responsible for Corrective Action: Debbie Gannon, Registrar Corrective Action: Certain students’ campus-level enrollment data was not accurately reported. The Registrar’s Office will determine why certain students falling outside of normal graduate submission schedules are not being captured in DegreeVerify files submitted to the National Student Clearinghouse. Manual submissions for these non-standard graduates will be performed until a reporting solution is identified. Anticipated Completion Date: August 15, 2025

View Audit 351979

Finding 548644 (2024-003)

None 2024

Queens University of Charlotte

NC

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

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. The University correctly determined the amount of Title IV ai...

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. The University correctly determined the amount of Title IV aid earned for a student within the required timeframes, but due to administrative oversight, omitted one of the required awards from the return update on the student account. A regular review of R2T4 calculations will be developed to ensure that the actual returns match the return calculations. Anticipated Completion Date: August 15, 2025

View Audit 351979

Finding 548640 (2024-008)

Significant Deficiency 2024

The Shaw University, Inc.

NC

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will review and revise its procedures for the frequency of ...

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will review and revise its procedures for the frequency of NSLDS reporting to ensure timely reporting of enrollment changes. The University will implement a monthly enrollment audit to ensure that any change in enrollment status is identified in a timely manner and reported to NSLDS. Anticipated Completion Date: June 30, 2025

View Audit 351972

Finding 548637 (2024-007)

Significant Deficiency 2024

The Shaw University, Inc.

NC

Internal Control / Segregation of Duties Student Financial Aid Subrecipient Monitoring

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of...

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of Title IV funds is processed in accordance with federal regulations, specifically within the required 45-day timeframe after determining a student has withdrawn from the university. The university will establish a quarterly audit and monitoring system to review all Title IV fund returns, ensuring compliance with federal guidelines. Anticipated Completion Date: June 30, 2025

View Audit 351972

Finding 548617 (2024-002)

Material Weakness 2024

City of West Sacramento

CA

Matching / Level of Effort / Earmarking

The Economic Development and Housing Department will implement procedures to ensure that all annual compliance documents are collected and maintained for the life of the loan.

View Audit 351958

Finding 548598 (2024-001)

None 2024

Visible Music College

TN

Student Financial Aid Matching / Level of Effort / Earmarking

AUDIT FINDING Finding 2024-001 Incorrect Title IV (R2T4) Calculation MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor’s finding and identification of a deficiency in our internal controls. MANAGEMENT'S CORRECTIVE ACTION PLAN We will enact stronger controls to en...

AUDIT FINDING Finding 2024-001 Incorrect Title IV (R2T4) Calculation MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor’s finding and identification of a deficiency in our internal controls. MANAGEMENT'S CORRECTIVE ACTION PLAN We will enact stronger controls to ensure that all R2T4s are accurately calculated and the proper amounts are refunded in a timely manner. EMPLOYEE/ DIVISION RESPONSIBLE Financial Aid Director TIMELINE AND ESTIMATED COMPLETION DATE Immediately

View Audit 351950

Finding 548595 (2024-003)

Significant Deficiency 2024

Benjamin Franklin Cummings Institute of Technology

MA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Franklin Cummings Tech recognizes the importance of submitting the correct dates for withdrawals. These e...

Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Franklin Cummings Tech recognizes the importance of submitting the correct dates for withdrawals. These errors found in the audit resulted from how our previous Student Information System dated status changes. Our new Student Information System, Jenzabar, has inherent system features that will control this process more effectively. To ensure this, the Registrar will review a minimum of 50% of the withdrawals processed since the previous file submission to ensure that the date matches the withdrawal date. The Controller will also review a sample of withdrawals on the file at least once per semester to ensure this process is being followed. Timeline for Implementation of Corrective Action Plan: April 2025 Contact Person: James Klasen, Registrar

View Audit 351935

Finding 548593 (2024-002)

Significant Deficiency 2024

Benjamin Franklin Cummings Institute of Technology

MA

Student Financial Aid Matching / Level of Effort / Earmarking

Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Given the continuing challenges of using an antiquated Student Information System to manage student withd...

Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Given the continuing challenges of using an antiquated Student Information System to manage student withdrawals, FC Tech has taken the following actions as of October 1, 2024: 1. Hired a New Director of Financial Aid (September 2024) 2. Converted our Student Information System from Unit 4/CAMS to Jenzabar 3. Implemented internal procedures that include staff from Financial Aid, FA Solutions (BFCIT third-party service provider), Student Accounts & Registrar’s Office Specific Controls Implemented: 1. FA Solutions will provide a monthly report identifying students that have withdrawn from BFCIT. This report will include: a. Student Name b. Date required funds must be returned c. Status of each withdrawal: i. Completed on-time ii. In process and still within timeframe to complete the return iii. In process and at risk of not completing timely 2. The new Financial Aid Director has created, and will oversee, a Withdrawal Tracking Spreadsheet to track the progress of all Withdrawals. This spreadsheet has built-in critical dates. 3. Inherent within our new Student Information System (Jenzabar) there are built in controls that will ensure compliance and assist with the timely processing of Withdrawals and the return of Federal Funds 4. Effective October 2024 a Management Report has been created that summarizes all active withdrawals. This report will be sent to the CFO and Controller no later than 10th business day of each month. Timeline for Implementation of Corrective Action Plan: October 2024 Contact Person: Sabina Yesmin, Director of Financial Aid

View Audit 351935

Finding 548583 (2024-005)

Material Weakness 2024

Dartmouth-Hitchcock Health and Subsidiaries

NH

Eligibility Procurement, Suspension & Debarment Subrecipient Monitoring

Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate cost...

Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate costs in a manner that aligns with the eligibility and income requirements of the award. Using this methodology, management will identify the eligible population and appropriately incur allowable expenses associated with the award. Management will initiate a bi-weekly process to review upcoming appointments and the most recent eligibility check on recurring patients. If, during this process, a patient is identified who requires an eligibility check based on award criteria (i.e., whichever is later: four weeks or the individual's next appointment), Management team will perform re-enrollment procedures to validate that the individual is still eligible. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

View Audit 351922

Finding 547987 (2024-003)

Material Weakness 2024

Umpqua Public Transportation District

OR

Cash Management Subrecipient Monitoring Material Weakness § 200.302 § 200.328 § 200.329

Finding 2024-003 – Fiscal Management (Material Weakness) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (53...

Finding 2024-003 – Fiscal Management (Material Weakness) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: During portions of the fiscal year, the District prepared reimbursement calculations relying on an internally developed spreadsheet tool, rather than using amounts solely obtained from the general ledger and supporting documentation. The reimbursement reports were prepared by management with limited review. Conflicts over review and other monitoring procedures occurred, and were not always resolved. Complete supporting documentation for the claimed costs were not always available. Claims and other financial reports due to ODOT were regularly submitted after the due dates. The late and/or unsubstantiated filings have resulted in lost claims for the District, and potential refunding of reimbursements received. Cause: Internal control procedures assuring timely and accurate preparation of reports and filing of the reimbursement requests were not designed or implemented adequately. Maintaining sufficient and accurate supporting documentation for each report was not possible because original data was not relied upon by management, to complete the reports and reimbursement requests. Effect or Potential Effect: The lack of effective internal control activities over cash management, including financial reporting, allowed for reporting and claims errors, from simple calculation errors to requests for reimbursements of unauthorized purposes. Improper financial reporting to the ODOT occurred regularly. Lack of timely filing of reimbursement requests for amounts claimed, resulted in lost revenues and claims that may be required to be returned. Questioned Cost: No Context: Delays in filing reimbursement claims, delays in filing financial reports to ODOT, and internal disputes regarding completion of grant reimbursement request procedures were evident. Weak or nonexistent controls over cash management, including fiscal management, may result in lost revenues and risks of creating unnecessary liabilities in the form of refunds due to ODOT. Repeat of a Prior-Year Finding: Yes Recommendation: The District should design and implement internal control policies and procedures for cash management, including fiscal management and financial reporting. Monitoring, information and communication control activities should also be designed and implemented as part of the effort the reduce the risk of continued matters of noncompliance related to cash management. District's Response: The District acknowledges the weaknesses and its intention of correcting weaknesses. Corrective Action Plan: The District’s General Manager resigned effective September 13, 2024. The Board has adopted a plan to procure qualified professional assistance to evaluate and restructure the organization and assist in daily management activities until a new General Manager can be hired and trained. Additional assistance for resolving these deficiencies has been offered by ODOT and accepted by the Board. Planned Implementation Date: October 31, 2024 Responsible Persons: District Board, Umpqua Public Transit District

View Audit 351895

Finding 547954 (2024-001)

Material Weakness 2024

County of El Dorado

CA

Eligibility Material Weakness Matching / Level of Effort / Earmarking

Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to proces...

Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to process Medi-Cal applications. o Ongoing recruitment efforts will continue to fill vacant positions, including the hiring additional trainees to build capacity for timely eligibility determinations. • Improving Internal Processes: o The County is conducting a review of workflows to identify inefficiencies and implement streamlined processes that eliminate bottlenecks. o Digital tools and automation are being introduced to enhance efficiency and accuracy case processing. • Providing Additional Support: o Overtime opportunities are being offered to eligibility specialists to expedite the processing of pending cases. o Applications are being assigned to Eligibility Specialists on a weekly basis to ensure consistent progress in reducing the backlog. • Enhancing Monitoring and Reporting: o Administrative staff are generating weekly reports from CalSAWS to track the status Medi-Cal pending applications and monitor progress. o Weekly meetings are being held with supervisors to review performance, discuss challenges, and adjust strategies as needed. • Strengthening Internal Controls: o The County is improving its internal controls to prevent future delays, including increased use of system reports to identify applications nearing the 45-day processing requirement, regular audits of the eligibility determination process and enhanced compliance training for staff. • Ongoing Evaluation and Adaptation: o Progress will be assessed weekly to ensure the implemented measures are effective. Adjustments will be made as needed to maintain compliance with the 45-day requirement. Proposed Completion Date: The county has already implemented this process and expects it to be completed by July 31, 2026.

View Audit 351887

Corrective Action Plans

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