Corrective Action Plans

Finding 371214 (2023-001)

None 2023

Wartburg College

IA

Student Financial Aid Reporting Questioned Costs

We identified two issues that lead to inaccurate reporting of enrollment statuses to NSLDS. One was human error; the other was a result of an override we had in the report to pull enrollment data. Our Institutional Research Office had the overrides in the enrollment report removed and developed a sy...

We identified two issues that lead to inaccurate reporting of enrollment statuses to NSLDS. One was human error; the other was a result of an override we had in the report to pull enrollment data. Our Institutional Research Office had the overrides in the enrollment report removed and developed a system where they will upload enrollment reports monthly to the Clearinghouse which will then update enrollment in NSLDS. This will also eliminate the need for the human task we had embedded in the withdraw reporting process. In addition, we are researching the possibility of reviewing withdrawal or graduation dates compared to the effective dates and enrollment statuses reported to the NSLDS to make sure they are accurate. At the time of the audit, a graduation date that past had not been reported to NSLDS. We did not have the final transcript from the study abroad institution to confirm all graduation requirements had been met. The graduation date has since been reported but it was not within the required timeframe. In the future we plan to do more aggressive outreach to the study abroad institution to receive final transcripts sooner. Name(s) of Contact Person(s) Responsible for Corrective Action: Jen Sassman, Executive Director of Financial Aid and Henrique Donat, Director of IT Application Services and Jen Beck, Institutional Researcher Anticipated Completion Date: The overrides were removed from the enrollment reports on June 28, 2023. The schedule to report enrollment monthly was also developed in June 2023.

View Audit 292920

Finding 371212 (2023-004)

Significant Deficiency 2023

Minneapolis College of Art and Design

MN

Student Financial Aid Reporting Questioned Costs

Corrective Action Planned: The registrar has been processing NSC files at least every 28 days during MCAD’s three academic terms. They will implement additional checks on enrollment to locate status changes within term. Also, they will begin reporting status changes that occur between terms, rather ...

Corrective Action Planned: The registrar has been processing NSC files at least every 28 days during MCAD’s three academic terms. They will implement additional checks on enrollment to locate status changes within term. Also, they will begin reporting status changes that occur between terms, rather than at the beginning of the following term. Name(s) of Contact Person(s) Responsible for Corrective Action: River Gordon, Registrar Anticipated Completion Date: March 1, 2024 for in-term updates; Jun 30, 2024 for between-term updates.

View Audit 292916

Finding 371194 (2023-007)

Significant Deficiency 2023

Granville County, North Carolina

NC

Questioned Costs Eligibility Matching / Level of Effort / Earmarking

Caseworkers are to review and verify income and deductions by policy standards. Food and Nutrition Lead workers and Supervisor will conduct second-party reviews on caseworkers. The Food and Nutrition Supervisor will go over errors found by second parties during their team's monthly meetings. The sup...

Caseworkers are to review and verify income and deductions by policy standards. Food and Nutrition Lead workers and Supervisor will conduct second-party reviews on caseworkers. The Food and Nutrition Supervisor will go over errors found by second parties during their team's monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisor due to performance and 4 for applications workers and 3 for redeterminations workers per month. The supervisor and lead workers will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisor and/or Lead workers will conduct monthly meetings which include mini trainings on errors found in second parties. Refresher training will be held quarterly and annually for in-depth training regarding policy areas in which the Supervisor and lead workers identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest training needed to the Supervisor to ensure that policy/procedures are being implemented accordingly. The supervisor will schedule and hold a meeting each month to inform Program Administrator, Heather Hayes, of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisor and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator monthly and at quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training will be held on Food and Nutrition policy sections 340 Deductions, 310 Budgeting New/Change/Terminated Income, and 315 Special Budgeting Income on January 24, 2024.

View Audit 292856

Finding 371193 (2023-006)

Significant Deficiency 2023

Granville County, North Carolina

NC

Questioned Costs Eligibility Reporting

Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. The supervisor will go over errors found by second parties during their team monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Superviso...

Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. The supervisor will go over errors found by second parties during their team monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisor will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2352 on November 29, 2022. Plan was discussed on November 17, 2023 with Lead Workers Michelle Ogle and Delta Elliot on a new team procedure regarding SSI terminations. Meeting will be held on November 28, 2023 discussing new procedure and a Training will be held by December 29, 2023 regarding SSI Expartes.

View Audit 292856

Finding 371192 (2023-005)

Significant Deficiency 2023

Granville County, North Carolina

NC

Questioned Costs Eligibility Reporting

Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. Family and Children Medicaid Lead Workers and the Supervisors will conduct second-par...

Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. Family and Children Medicaid Lead Workers and the Supervisors will conduct second-party reviews on caseworkers. Both Adult Medicaid and Family and Children Medicaid supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisors will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisors due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisors will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. Supervisors will schedule and hold a meeting each month to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2250 on November 29, 2022, DSS Terminial Message regarding Admin Letter 11-22 dated 12/12/2022 on COLA procedures was provided to Adult Medicaid team members on 12/12/2022. Meeting held regarding COLA income on 12/29/2022. Update meeting regarding the COLA increases will be held by December 31, 2023 when policy guidelines are provided by state. Family and Children Medicaid sections MA-3300 was held on November 30, 2022 regarding income. Meeting regarding Incorrect income will be held on by November 30, 2023.

View Audit 292856

Finding 371191 (2023-004)

Significant Deficiency 2023

Granville County, North Carolina

NC

Questioned Costs Eligibility Internal Control / Segregation of Duties

Corrective Action: Proposed completion date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Kim Grissom, Family and Children's Medicaid Supervisor, Shelia Morton, Family and Children's Medicaid Supervisor, and Vanness Taylor, Adult Medicaid Supervisor To ensure that the casewo...

Corrective Action: Proposed completion date: Finding 2023-005 Inaccurate Information Entry Name of contact person: Kim Grissom, Family and Children's Medicaid Supervisor, Shelia Morton, Family and Children's Medicaid Supervisor, and Vanness Taylor, Adult Medicaid Supervisor To ensure that the caseworkers do not repeat these errors, the following will happen: Adult Medicaid Documentation Templated was updated November 13, 2023. Training was held on July 6, 2023 for Recertifications for Adult Medicaid. Adult Meeting will be held on November 28, 2023. Family and Children held team meetings on November 30, 2022, January 26, 2023, and May 23, 2023. Family and Children meeting will be held by November 30th, 2023. State mandatory Training was held for all Medicaid Staff on July 25, 26, or 27, 2023 for Mastering Medicaid Policy , MAGI Recertifications and NCFAST 20020, and September 26, 27, or 28, 2023 Authorized Representatives and NCFAST 20020 Reminders. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. Family and Children Medicaid Lead Workers and the Supervisors will conduct second-party reviews on caseworkers. Both Adult Medicaid and Family and Children Medicaid supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisors will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator, Staff Development Specialists, and Human Services Planner Evaluator for monthly and quarterly refresher trainings.

View Audit 292856

Finding 371190 (2023-003)

Significant Deficiency 2023

Granville County, North Carolina

NC

Questioned Costs Eligibility

Corrective Action: Proposed completion date: Finding 2023-004 Inadequate Request for Information Name of contact person: Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct s...

Corrective Action: Proposed completion date: Finding 2023-004 Inadequate Request for Information Name of contact person: Caseworkers are to review the determinations tab and policy manual to properly ensure that the case is showing correctly. Adult Medicaid Lead workers and Supervisor will conduct second-party reviews on caseworkers. The supervisor will go over errors found by second parties during their team monthly meetings. The supervisor will hold individual performance meetings if cited for the same error. Lead Workers and Supervisor will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by the Supervisor due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisor will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly.The Supervisor will schedule and hold a meeting to inform Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invite to Program Administrator Staff Development Specialists and Human Services Planner Evaluator for monthly and quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on Adult Medicaid section MA-2230 on Janaury 31, 2023, July 6, 2023 and September 28, 2023. Documentation Templates were recently updated as of November 13, 2023. Meeting regarding the cited errors will be held on November 28, 2023.

View Audit 292856

Finding 371189 (2023-002)

Significant Deficiency 2023

Granville County, North Carolina

NC

Questioned Costs Subrecipient Monitoring Cash Management

Finding 2023-002 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed completion date: Finding 2023-003 Inaccurate Resources Entry Name of contact person: For the Year Ended June 30, 2023 Corrective Action Plan Section III - Federal Award Findings and Questioned Co...

Finding 2023-002 IV-D Cooperation with Child Support Name of contact person: Corrective Action: Proposed completion date: Finding 2023-003 Inaccurate Resources Entry Name of contact person: For the Year Ended June 30, 2023 Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Section II - Financial Statement Findings July 1, 2023 Stephen McNally, Finance Director The Finance Department will attempt to make all necessary transfers of funds between Forfeiture accounts in the current period. However, this correction notification from US Treasury was not sent to the Finance department until after the reporting period in which the transaction took place. Kim Grissom, Family and Children's Medicaid Supervisor and Shelia Morton, Family and Children's Medicaid Supervisor Family and Children Medicaid Lead Workers and Supervisors will conduct second-party reviews on caseworkers. The supervisors will go over errors found by second parties during their team monthly meetings. The supervisors will hold individual performance meetings if cited for the same error. Lead Workers and Supervisors will conduct 100% second parties on caseworkers in their probationary period of 6 months unless extended by Supervisors due to performance and 5 applications and redeterminations on all other caseworkers per month. The supervisors will also ensure that caseworkers are up to date on changes that may come up and ensure that they give proper instruction when needed. Supervisors and/or Leadworkers will conduct monthly meetings which including mini trainings on errors found in second parties. Refresher trainings will be held quarterly for indept training regarding policy areas in which the Supervisors identify the need for. The Human Service Planner Evaluator will help track of repetitive errors and suggest trainnings needed to Supervisors to ensure that policy/procedures are being implemmented accordingly. The Supervisors will schedule and hold a meeting to inform the Program Administrator of the errors found on second-party findings and provide a copy of the individual’s performance meeting held with the worker on any repetitive errors. Supervisors and or Lead workers will send training invites to Program Administrator, Staff Development, and Human Services Planner Evaluator, for monthly and at quarterly refresher trainings. To ensure that the caseworkers do not repeat these errors, the following will happen: policy training was held on November 30, 2022, for Family and Children Medicaid section MA- 3365. Documentation Template was last updated on November 3, 2023, which includes IVReferral reminder. Family and Children meeting will be held by November 30, 2023.

View Audit 292856

Finding 371188 (2023-001)

Significant Deficiency 2023

The Chicago School-Cal INC Dba the Chicago Sch of Pro Psychology

IL

Special Tests & Provisions Questioned Costs Matching / Level of Effort / Earmarking

Corrective Action Plan – The Chicago School Identifying Number: 2023-001 Finding: Special Tests and Provisions- Lack of Maintaining Verification Documents Applicable Regulation: Per 34 CFR 668.57, if an applicant is selected to verify information, an institution must obtain the specified documentati...

Corrective Action Plan – The Chicago School Identifying Number: 2023-001 Finding: Special Tests and Provisions- Lack of Maintaining Verification Documents Applicable Regulation: Per 34 CFR 668.57, if an applicant is selected to verify information, an institution must obtain the specified documentation. Finding: During testing of students selected for verification, for 1 out of 14 students selected for testing, the College could not provide the supporting verification documents. Summary: According to our records, after this student was selected by the Department of Education for verification, the student submitted the required verification worksheet (V4) on 8/22/22. The financial aid advisor that performed the verification left the College shortly after performing the verification and did not properly save and maintain the documents. On 8/25/23, staff reached out to the student via phone and email to retrieve a copy of the previously submitted V4 worksheet but did not receive a response. The advisor that originally verified the file is no longer employed by The Community Solution. Corrective Action Taken or Planned: On 7/1/23, the Financial Aid Training Department assumed the role and responsibilities of reviewing all financial aid files for accuracy. The department conducts reviews on a weekly basis with oversight provided by the Financial Aid Training Manager. As the result of each weekly audit, a report is compiled and provided to both financial aid leadership and staff. If there are any missing documents or errors found, these are tracked through to completion by the training department. Additionally, the Financial Aid team provides 1:1 training to staff if errors are uncovered during the weekly review. The error in question did not create any financial liabilities for the student or institution as the aid received was not need based. The institution informed RSM of this error and the corrective actions taken. Contact Person Lawrence McGhee, Associate Vice President of Financial Aid lawrencemcghee@tcsedsystem.edu Anticipated Completion Date July 1, 2023

View Audit 292844

Finding 371187 (2023-001)

Material Weakness 2023

Kansas Health Science Center, Inc.

IL

Questioned Costs Student Financial Aid Eligibility

Over Award Review and Correction Action Taken – Kansas Health Science Center (KHSC) Identifying Number: 2023-001 Finding: Eligibility – Determining Federal Direct Student Loan Awards Applicable Regulation: Per 34 CFR 686.203(b)(iii), in the case of a graduate or professional student for a period ...

Over Award Review and Correction Action Taken – Kansas Health Science Center (KHSC) Identifying Number: 2023-001 Finding: Eligibility – Determining Federal Direct Student Loan Awards Applicable Regulation: Per 34 CFR 686.203(b)(iii), in the case of a graduate or professional student for a period of enrollment beginning on or after July 1, 2012, the total amount the student may borrow for any academic year of study under the Direct Unsubsidized Loan program may not exceed $8,500. Per 34 CFR 685.203(c)(2)(v), the additional amount that a student described in paragraph (c)(1)(i) of this section may borrow under the Direct Unsubsidized Loan Program for any academic year of study may not exceed the following: in the case of a graduate or professional student, $12,000. Finding: During testing of eligibility, 7 out of 7 students selected for testing were over awarded Unsubsidized Federal Direct Loans. KHSC improperly awarded 61 out of 61 students Unsubsidized Federal Direct Loan in excess of the maximum amount for one academic year, amounting to [$4,445] per student, for a cumulative over award of [$271,146]. Summary: Prior to the commencement of the independent audit conducted for the fiscal year ended May 31, 2023, the institution discovered that it had over awarded Unsubsidized Federal Direct Loan funds to its students. Specifically, the institution awarded additional Unsubsidized Federal Direct Loan funds based on 12-month academic calendar instead of prorating the award based on a 10-month academic calendar. This error resulted in an over award of [$4,445] per student. The institution conducted a file review and refunded all amounts owed to the Federal Student Aid programs because of the file review. The institution also informed the auditor of this error. Corrective Action Taken or Planned: Once the above noted error was discovered, the institution conducted an audit of all student aid packages for students enrolled in the 2022-2023 academic year. It was determined that 61 current students had been over awarded by a net amount of $4,445, for a total of $271,146. Findings were compiled and a plan was created to return over awarded funds and communicate the error to students. The institution also consulted with the Department of Education to confirm its revised calculation was appropriate. The institution returned the funds between July 5-July 20, 2023. Further, the institution made students whole by forgiving any student balances that would have been paid by the over award amount. Emails were sent to all impacted students on July 3, 2023 notifying them of the error. The institution also subsequently notified students that any account balance that remained based on the reversal of the over award would be forgiven. Students who received an estimate financial aid award with the incorrect figures, but who had not yet received aid, were notified of the error and provided updated award information. To ensure this does not happen again the institution has updated their internal student finance audit to include a review of all aid eligibility in conjunction with the next year’s academic calendar for each class of students. Upon any determination that future aid should be prorated, calculation(s) will be completed and reviewed with leadership before implementation. An internal review and approval process will then be enacted and documented. The institution informed RSM of this error and the corrective actions taken. Contact Person Lawrence McGhee, Associate Vice President of Financial Aid, lawrencemcghee@tcsedsystem.edu Completion Date July 20, 2023

View Audit 292837 Questioned Costs: $1

Finding 371171 (2023-006)

Significant Deficiency 2023

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.303 § 200.306 § 200.403

Finding 2023-006: Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility...

Finding 2023-006: Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. The secondary review of match claim workbook did not identify the clerical errors. During testing of expenditures, the following items were identified: a) The number of hours an employee worked per the approved timesheet vs. the hours claimed in the match claim workbook resulted in a clerical error. (1 instance) b) Per review of the supporting timesheet and paystub, an employee had mobile crisis pay which was not accurately reduced in the calculation for match in the match claim workbook (2 instances). Responsible Individuals: Staff Supervisors (Michelle Theesfeld, Kari Van Dam) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. CEO will review all grant staff that also provide mobile crisis to ensure that mobile crisis pay is removed before allocating salary and fringe benefits to grant programs. Anticipated Completion Date: Beginning in January 2023, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

View Audit 292802

Finding 371169 (2023-005)

Significant Deficiency 2023

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking § 200.303 § 200.430

Finding 2023-005: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.958 Program Name: Block Grants for Community Mental Health Services Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in...

Finding 2023-005: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.958 Program Name: Block Grants for Community Mental Health Services Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. Employees did not enter all nonfederal hours within the ClickTime system and the secondary review of the employee ClickTime timecards did not identify the missing hours. In addition, the secondary review of federal grant expenditure tracking spreadsheet did not identify the missing pay periods. During testing of expenditures, the following items were identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (2 instances). b) The tracking spreadsheet did not reflect the entire months payroll and instead only included 2 weeks of payroll and benefits which resulted in a calculation error for expenses allocated to the grant (1 instance). Responsible Individuals: Staff Supervisors (Missy Martini, Billie Jo Hovick, Taylor Prather, Kari Anderson) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. Anticipated Completion Date: Beginning in January 2023, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

View Audit 292802

Finding 371168 (2023-004)

Material Weakness 2023

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking § 200.303 § 200.430

Finding 2023-004: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: The Center’s controls did not detect or correct the errors...

Finding 2023-004: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. Employees did not enter all nonfederal hours within the ClickTime system and the secondary review of the employee ClickTime timecards did not identify the missing hours, the incorrectly tracked hours, and double tracked time. Also, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. In addition, the grant was overcharged for nonpayroll as it relates to a gym membership claimed for a customer of the grant. During testing of expenditures, the following items were identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (2 instances). b) Calculation errors for expenses allocated to the grant (2 instances). c) Employee’s overtime hours were not properly tracked in ClickTime (2 instances). d) Employee tracked paid time off under PTO and CCBHC lines in ClickTime (1 instance) causing it to be double tracked. e) Grant was overcharged as it relates to a client’s gym membership (1 instance). Responsible Individuals: Project Directors (Rebecca McCrackin, Missy Martini, Billie Jo Hovick), Project Accounts Manager (Marsha Bomgaars) and CEO (Dan Ries) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. The CEO will review all client assistance payments for accuracy when doing monthly expense review/approval. Anticipated Completion Date: Beginning in January 2023, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

View Audit 292802 Questioned Costs: $1

Finding 371167 (2023-003)

Significant Deficiency 2023

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking § 200.303 § 200.430

Finding 2023-003: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL#93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: The Center’s controls did not detect or correct the errors identified, which result...

Finding 2023-003: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL#93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. Employees did not enter all nonfederal hours within the ClickTime system and the secondary review of the employee ClickTime timecards did not identify the missing hours. In addition, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. During testing of expenditures, the following items were identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (3 instances). b) Calculation errors for expenses allocated to the grant (1 instance). Responsible Individuals: Staff Supervisors (Christina Eggink-Postma, Sarah Heinrichs, Stephanie Pohar) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. Anticipated Completion Date: Beginning in January 2023, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

View Audit 292802

Finding 371163 (2023-002)

Significant Deficiency 2023

Franklin County, North Carolina

NC

Eligibility Questioned Costs Significant Deficiency

Finding: 2023-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the e...

Finding: 2023-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2024

View Audit 292790

Finding 371148 (2023-003)

Significant Deficiency 2023

La Salle University

PA

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. 84.038 Recommendation: We recommend the University evaluate its procedures and policies around recordkeeping and record retention. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...

Student Financial Assistance Cluster – Assistance Listing No. 84.038 Recommendation: We recommend the University evaluate its procedures and policies around recordkeeping and record retention. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will generate a master list of all prior students with Perkins Loans. That master list will track location of files/documentation and provide the tracking to have all files secured all in one properly secured location. Name(s) of the contact person(s) responsible for corrective action: Michele McDevitt Planned completion date for corrective action plan: In progress as of February 28, 2024. A complete master list of students who received Perkins loans will be cross checked against the student’s actual file contained in fire proof cabinets, verifying each student’s master promissory note is on site. This process will be completed no later than August 1, 2024. If the United State Department of Education has questions regarding this plan, please contact Michele McDevitt at mmartin@lasalle.edu or 215.951.1651

View Audit 292767

Finding 371143 (2023-001)

Significant Deficiency 2023

La Salle University

PA

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are retur...

Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.033, 84.038, 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are returned within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will evaluate the current refund process and make revisions to process to ensure any credit balances of Title IV aid are returned within the required timeframe. The university’s goals is to automate the refund process to reduce the chance of human error, and placing the refund process on a schedule to ensure refunds are processed within the appropriate window of time. Name(s) of the contact person(s) responsible for corrective action: Michele McDevitt Planned completion date for corrective action plan: September 9, 2024 – first rounds of Fall 2024 refunds

View Audit 292767

Finding 371142 (2023-001)

Significant Deficiency 2023

Our Lady of the Lake University of San Antonio

TX

Questioned Costs Student Financial Aid Reporting

Our Lady of the Lake University of San Antonio FY 2023 Single Financial Audit Finding Response Corrective Action Plan – Reconciliation of COD Monthly School Account Statement Compliance Finding: The Department of Education’s (DoE) School Account Statement (SAS), downloaded electronically from the C...

Our Lady of the Lake University of San Antonio FY 2023 Single Financial Audit Finding Response Corrective Action Plan – Reconciliation of COD Monthly School Account Statement Compliance Finding: The Department of Education’s (DoE) School Account Statement (SAS), downloaded electronically from the Common Origination Destination (COD) website, was not being reconciling monthly as required by the Student Financial Aid/ Direct Loan Program. Criteria or Specific Requirement: Per the Student Financial Aid/ Direct Loan Program requirements with the DoE, every school is required to reconcile their SAS to their accounting system records at least monthly. This statement is issued to each participating school through the SAIG mailbox monthly. The auditors noted 34 CFR 685.102(b), 385.300(b), 685.301, and 303 as the compliance regulation. Cause of Noncompliance: It appears that the SAS was reconciled monthly per the compliance requirement in recent years, but with high turnover and periods of under-staffing in the Accounting department this procedure was changed to one that did not meet the above requirement. Although OLLU did regularly reconcile the accounting system records with reports from COD, it was not the official monthly SAS statement. OLLU’s modified procedures did not completely meet the compliance requirement but did offer some mitigating procedures. Institution Response: OLLU has already begun coordinating processes between its Accounting and Financial Aid departments to download the monthly SAS into the university’s system electronically, where Accounting will then reconcile the statement monthly as a part of its month-end close procedures. The Financial Aid Director will be responsible for ensuring that the statement is downloaded monthly as a part of the regular electronic data file transfer between OLLU and the Department of Education. The Senior Accountant in the Accounting department will generate the report in Colleague via the DRSS process and reconcile the SAS statement to cash records. The Director of Accounting and Reporting will review the reconciliation monthly.

View Audit 292763

Finding 371132 (2023-001)

Significant Deficiency 2023

Southwest Baptist University

MO

Questioned Costs Student Financial Aid Reporting

A plan has been developed to take corrective action regarding findings 2023-001 in our audit for the year ended May 31, 2023. Due to previous manual processes and significant staffing turnover in the Accounting and Financial Aid areas, this summer, we discovered some of the R2T4 calculations were...

A plan has been developed to take corrective action regarding findings 2023-001 in our audit for the year ended May 31, 2023. Due to previous manual processes and significant staffing turnover in the Accounting and Financial Aid areas, this summer, we discovered some of the R2T4 calculations were missed. Once this was discovered, we went back through and ensured all the withdrawal calculations were done and funds returned, even though they were outside the compliance timeframe. While testing the return of Title IV funds from a sample, FORVIS noted that two students did not have a refund calculation completed in a timely manner. These findings had been discovered by SBU and corrected, and funds were returned earlier, but they were still outside the compliance timeframe, which required an audit finding. To address these issues, SBU employees have taken the following corrective measures: 1. We reworked the reporting process for withdrawals. All withdrawals now go to the Associate Provost regardless of campus or program. They are then processed by the Registrar’s Office and placed in a shared drive. Once there, they are reviewed weekly by the Financial Aid Office, and R2T4s are completed in a timely manner. This process no longer relies on a member of the Accounting Office to notify Financial Aid of a withdrawal. 2. R2T4 requests are completed by one Financial Aid staff member and verified and processed by another to ensure accuracy and reliability. 3. We have implemented an administrative withdrawal process to give campus and program directors the ability and authority to withdraw students who are no longer in attendance to limit the number of all Fs at the end of the semester. Sincerely, Terri Rogers Controller

View Audit 292760 Questioned Costs: $1

Finding 371100 (2023-001)

Material Weakness 2023

Umatilla Morrow Head Start, Inc.

OR

Internal Control / Segregation of Duties Questioned Costs Material Weakness § 200.302

Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. (UMHS, Inc.) partnered with an independent accounting firm to streamline processes and develop templates for year-end closure. The agency used this opportunity to increase knowledge and understanding o...

Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. (UMHS, Inc.) partnered with an independent accounting firm to streamline processes and develop templates for year-end closure. The agency used this opportunity to increase knowledge and understanding of needs associated with this task. As the fiscal department moves forward, systems and tools have been implemented to ensure timely closing and accurate tracking of this process. UMHS will continue to utilize the checklists put in place last fiscal year to guide month-end processes and reconciliations. Fiscal Management will review, monthly, the completion of said duties and will address any issues with staff immediately. Ongoing training will be done to ensure all fiscal staff members understand their role and duties within the agency. Bank reconciliations will continue to be completed monthly. The Executive Director, Director of Finance, Treasurer of the Board of Directors, or Other Designee will review the information and approval will be documented. UMHS will focus on segregation of duties within the fiscal department and ensure proper documentation is maintained. Person(s) Responsible: Executive Director, Director of Finance, Treasurer of the Board of Directors, or Other Designee Timing for Implementation: Immediately and Ongoing Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. (UMHS, Inc.) partnered with an independent accounting firm to streamline processes and develop templates for year-end closure. The agency used this opportunity to increase knowledge and understanding of needs associated with this task. As the fiscal department moves forward, systems and tools have been implemented to ensure timely closing and accurate tracking of this process. UMHS will continue to utilize the checklists put in place last fiscal year to guide month-end processes and reconciliations. Fiscal Management will review, monthly, the completion of said duties and will address any issues with staff immediately. Ongoing training will be done to ensure all fiscal staff members understand their role and duties within the agency. Bank reconciliations will continue to be completed monthly. The Executive Director, Director of Finance, Treasurer of the Board of Directors, or Other Designee will review the information and approval will be documented. UMHS will focus on segregation of duties within the fiscal department and ensure proper documentation is maintained. Person(s) Responsible: Executive Director, Director of Finance, Treasurer of the Board of Directors, or Other Designee Timing for Implementation: Immediately and Ongoing Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. (UMHS, Inc.) partnered with an independent accounting firm to streamline processes and develop templates for year-end closure. The agency used this opportunity to increase knowledge and understanding of needs associated with this task. As the fiscal department moves forward, systems and tools have been implemented to ensure timely closing and accurate tracking of this process. UMHS will continue to utilize the checklists put in place last fiscal year to guide month-end processes and reconciliations. Fiscal Management will review, monthly, the completion of said duties and will address any issues with staff immediately. Ongoing training will be done to ensure all fiscal staff members understand their role and duties within the agency. Bank reconciliations will continue to be completed monthly. The Executive Director, Director of Finance, Treasurer of the Board of Directors, or Other Designee will review the information and approval will be documented. UMHS will focus on segregation of duties within the fiscal department and ensure proper documentation is maintained. Person(s) Responsible: Executive Director, Director of Finance, Treasurer of the Board of Directors, or Other Designee Timing for Implementation: Immediately and Ongoing

View Audit 292742

Finding 371070 (2023-002)

Significant Deficiency 2023

Furman University

SC

Procurement, Suspension & Debarment Questioned Costs Significant Deficiency § 200.212 § 200.318

2023-002 Suspension and Debarment Recommendation: We recommend the University document suspension and debarment procedures going forward for any aggregate disbursements with vendors greater than $25,000. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...

2023-002 Suspension and Debarment Recommendation: We recommend the University document suspension and debarment procedures going forward for any aggregate disbursements with vendors greater than $25,000. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A signed debarment letter is now a required document for vendors greater than $25,000. This letter is verified by our University procurement office before the item is purchased. Name(s) of the contact person(s) responsible for corrective action: Dawn Durham Planned completion date for corrective action plan: 10/6/2023

View Audit 292738

Finding 371066 (2023-001)

Significant Deficiency 2023

Furman University

SC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Department of Education 2023-001 Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend that the College review the updated GLBA requirements and ensure their Written Information Security Program (WISP) includes all required elements. We do note that after June 30, 2023 the University has upd...

Department of Education 2023-001 Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend that the College review the updated GLBA requirements and ensure their Written Information Security Program (WISP) includes all required elements. We do note that after June 30, 2023 the University has updated the WISP to include all of the required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Updated WISP to include all required elements. Name(s) of the contact person(s) responsible for corrective action: Dawn Durham Planned completion date for corrective action plan: 10/19/2023

View Audit 292738

Finding 371065 (2023-001)

None 2023

Villanova University

PA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

The University agrees with this finding. As a result, the University has taken the following actions to be executed in FY24: Verification The University agrees with this finding. The Office of Financial Assistance has created additional reporting to confirm verification is completed for all required...

The University agrees with this finding. As a result, the University has taken the following actions to be executed in FY24: Verification The University agrees with this finding. The Office of Financial Assistance has created additional reporting to confirm verification is completed for all required verifications. These reports will be run weekly and reviewed by a financial aid counselor, to confirm all V4 and V5 are completed and not waived. Disbursement The University agrees with this finding. The Office of Financial Assistance has made additional disbursement monitoring checks within the Banner system. These checks will stop a fund from disbursing unless the required documents have been satisfied in the system. These will be reviewed weekly on disbursement error reports shared with the office. 14-day refund Period The University agrees with this finding. The Bursar's Office implemented the following procedure when the finding was identified: To avoid such errors in the future and to ensure that the Bursar's Office adheres to the 14-day requirement, the Bursar's Office has established a procedure whereby the Refund Specialist must complete a federal refund report and provide it to the Associate Bursar for sign-off before running a subsequent report. This will ensure that refunds are not overlooked due to staff not processing a report in its entirety. Notification The University agrees with this finding. This does appear to have been an error with the job run on the identified sample day and not a human error. The Bursar's Office is reviewing each notification run output to ensure all notifications are produced. If there is any issue, the Bursar's Office will ensure any unsent e-mails are sent in the proper time.

View Audit 292736

Finding 371063 (2023-005)

Significant Deficiency 2023

Drury University

MO

Student Financial Aid Questioned Costs Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Actions - Drury University accepts this finding. • Upon discovery of a programming error within the enrollment report obtained from the Jenzabar system for transmission to the National Student Clearinghouse (NSC), the report was immediately corr...

Views of Responsible Officials and Planned Corrective Actions - Drury University accepts this finding. • Upon discovery of a programming error within the enrollment report obtained from the Jenzabar system for transmission to the National Student Clearinghouse (NSC), the report was immediately corrected by the Registrar and rechecked prior to its transmission to NSC in October 2023. The Registrar has expressed confidence that the error is corrected but has set up additional system queries to be checked against the report to ensure accuracy prior to transmission of future reports. • Financial Aid Office and Registrar’s Office will review and compare actual enrollment and program information with the data reported in NSLDS after each submission. Any corrections will be made as soon as is practicable, but not later than 30 days after the discrepancy is identified.

View Audit 292735

Finding 371061 (2023-004)

Significant Deficiency 2023

Drury University

MO

Student Financial Aid Questioned Costs Matching / Level of Effort / Earmarking

View of Responsible Officials and Planned Corrective Actions – Drury University accepts this finding and has created a Corrective Action Plan (CAP). In all four cases identified in the finding, the late return of funds were for students who unofficially withdrew (ceased attending) and did not notif...

View of Responsible Officials and Planned Corrective Actions – Drury University accepts this finding and has created a Corrective Action Plan (CAP). In all four cases identified in the finding, the late return of funds were for students who unofficially withdrew (ceased attending) and did not notify the institution. Henceforth, within 10 days of grades being posted at the end of each semester, Financial Aid will liaise with the Registrar’s Office to review all unearned F grades and determine if a return of funds is required. Additional automated tasks already have been created in the PowerFAIDs software that notify the Financial Aid Administrator (FAA) when a Return of Title IV Funds (R2T4) has been completed but not processed. The FAA will monitor R2T4 processing and returns to ensure that returns are processed within the required timeframe.

View Audit 292735

Corrective Action Plans

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