Corrective Action Plans

Finding 49626 (2022-001)

Significant Deficiency 2022

Lesley University

MA

Questioned Costs Student Financial Aid Eligibility

Finding ? Return of Funds Condition Out of forty students selected for testing, nine students were under awarded Pell grants based on their EFC and COA. This is not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The University begins to award students...

Finding ? Return of Funds Condition Out of forty students selected for testing, nine students were under awarded Pell grants based on their EFC and COA. This is not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The University begins to award students prior to the new Pell Grant schedule release in late March. In April our software provider, Ellucian, releases an update for us to upload with the new Pell Grant schedule. This update was completed but some of the Pell Grants that had been packaged prior to the update were not reprocessed and repackaged with the new Pell Grant amounts. This error was due to a loss of personnel that had previously managed the reprocessing of the Pell Grants. Management has already reprocessed any students for 2022-23 to ensure correctness of Pell awards for the current year. Additionally, management has adopted new step by step procedures in writing to assist with the reprocessing/repackaging of Pell Grant awards to ensure that proper practices will be followed on a forward basis. Management is also in the process of reviewing 21-22 Pell awards and will disburse any shortfalls by December 31, 2022 to impacted students. Responsible Official: Frank Mullen Completion Date: 10/26/2022

View Audit 42506 Questioned Costs: $1

Finding 49615 (2022-002)

Significant Deficiency 2022

Lenoir County, North Carolina

NC

Eligibility Questioned Costs

Corrective Action: Supervisors and Lead Workers randomly conduct 2nd party reviews on case actions completed by IMC workers. All new hires go through and extensive training plan and are only released when error rate is 5% or less. Workers must continue to maintain an overall rating of 95% to be rele...

Corrective Action: Supervisors and Lead Workers randomly conduct 2nd party reviews on case actions completed by IMC workers. All new hires go through and extensive training plan and are only released when error rate is 5% or less. Workers must continue to maintain an overall rating of 95% to be released from all of their work being 100% 2nd party reviewed. Work issues and errors are corrected immediately when discovered and Lead Workers and Supervisors provide training to the unit or individuals, as needed. The County remains proactive in resolving all errors cited while battling issues with turnovers, limited staff, and inexperienced staff. An effective training plan has been implemented and is administered by the Staff Development Specialist and the Lead Worker Unit. Monthly and one-on-one conferences are conducted to discuss error citing found and coaching or refresher trainings are conducted. Proposed Completion Date: Immediate actions have been taken to resolve issues cited. The County continues to complete 2nd party reviews on each worker and evaluate error trends cited for corrections needed through coaching, refresher courses or training. Trainings pertinent to the specified findings will be completed by 12/01/2022.

View Audit 42398

Finding 49614 (2022-001)

Significant Deficiency 2022

Lenoir County, North Carolina

NC

Questioned Costs Eligibility Internal Control / Segregation of Duties

Corrective Action: Lead Workers will run the exparte logs weekly and assign them to workers and send notifications to respective supervisors to oversee. Lead Workers and Supervisors will monitor the reports to ensure reviews are completed within 30 days of receipt. Lead Workers will have the overall...

Corrective Action: Lead Workers will run the exparte logs weekly and assign them to workers and send notifications to respective supervisors to oversee. Lead Workers and Supervisors will monitor the reports to ensure reviews are completed within 30 days of receipt. Lead Workers will have the overall responsibility to ensure that report and reviews remain in compliance and are worked thoroughly and correctly. Lead Workers and Supervisors will monitor and train new workers and ensure workers are able to retain policy knowledge and apply said knowledge to case actions accurately. The Supervisor over the Lead Workers will conduct conferences and discuss and monitor report findings for continued timely completion. Proposed Completion Date: Immediate action taken to resolve issues found. This task will be ongoing and will be mitigated through training and implementation of more effective fiscal controls, with a proposed completion by 12/01/2022. These case citing?s resulted from tasks being assigned to workers who were no longer employed or moved to new positions and failed to complete case actions before leaving or moving from assigned job post. This citing was also a result of limited staff to monitor the tasks once position was vacated. The County has made every effort to minimize and mitigate the issues and findings cited and to strengthen the training process for the Medicaid Unit.

View Audit 42398

Finding 49609 (2022-001)

Significant Deficiency 2022

Alaska Works Partnership, Inc.

AK

Questioned Costs Reporting Significant Deficiency

Name of Contact Person: Melody Austin, Chief Financial Officer 161 Klevin Street, Suite 207 Anchorage, AK 99508 (907)569-4733 maustin@alaskaworks.org Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Corrective Action Plan Alaska Works Partnership...

Name of Contact Person: Melody Austin, Chief Financial Officer 161 Klevin Street, Suite 207 Anchorage, AK 99508 (907)569-4733 maustin@alaskaworks.org Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Corrective Action Plan Alaska Works Partnership will ensure timely year end closing and weekly review of audit schedules and progress of audit team to ensure timely reporting and on time completion and audit and submission of AWP?s audit to State/Federal Audit Department. Other possible options: A. Start Audit earlier for FY 23 Audit Year B. Find another audit company to do Audit for FY 23 year Expected Completion Date Fiscal Year 2023

View Audit 42286

Finding 49601 (2022-002)

Material Weakness 2022

Rock County

WI

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2022-002 Program ALN: 93.498 Program Title: COVID-19 Provider Relief Funds Award Number/Year: Not applicable / 2022 Federal Agency: U.S. Department of Health and Human Services Repeat of Finding 2021-004 Condition Two of two reports selected for testing were not reviewed and appr...

Finding 2022-002 Program ALN: 93.498 Program Title: COVID-19 Provider Relief Funds Award Number/Year: Not applicable / 2022 Federal Agency: U.S. Department of Health and Human Services Repeat of Finding 2021-004 Condition Two of two reports selected for testing were not reviewed and approved by an independent person separate from the preparer prior to submission to HHS. In addition the County did not maintain supporting documentation to support the amounts reported. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: The next report due will include documentation of review and approval by an independent person separate from the preparer. In addition, supporting documentation to support the amounts reported will be maintained. Name(s) of Contact Person(s) Responsible for Corrective Action: Rock Haven Nursing Home Director and Rock Haven Business Manager. Anticipated Completion Date: The corrective action will be completed at the time the next report is due.

View Audit 42483

Finding 49594 (2022-005)

Material Weakness 2022

Taos Health Systems, Inc.

NM

Questioned Costs Cash Management HUD Housing Programs § 200.302 § 200.303

COVID-19 Provider Relief Fund ? AL No. 93.498 Recommendation: Our auditors recommended the Organization evaluate its financial reporting processes and controls to determine whether additional controls over the preparation of any Provider Relief Fund reports are needed to ensure the reports are prep...

COVID-19 Provider Relief Fund ? AL No. 93.498 Recommendation: Our auditors recommended the Organization evaluate its financial reporting processes and controls to determine whether additional controls over the preparation of any Provider Relief Fund reports are needed to ensure the reports are prepared in line with the Provider Relief Fund guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management?s response: The Organization missed reducing the costs claimed against PRF by the amounts reimbursed through the Medicare cost report. The Organization did have additional lost revenues though that would offset these costs claimed and wouldn?t result in a repayment of the funds. We would look to HRSA for guidance on how you would like us to update our Phase 1 PRF report or how you would like to see this corrected. Also, the CFO will listen to webinars to receive education for Phase IV funds that were received by the Organization to ensure compliance with the reporting requirements. COVID-19 Provider Relief Fund ? AL No. 93.498 (Continued) Name(s) of the contact person(s) responsible for corrective action: Connie Prewitt, Interim CFO Planned completion date for corrective action plan: Will implement in fiscal year 2023.

View Audit 42385 Questioned Costs: $1

Finding 49589 (2022-001)

Significant Deficiency 2022

Tahlequah Hospital Authority Dba Northeastern Health System

OK

Questioned Costs Reporting Significant Deficiency § 200.303

Consideration of Amounts Reported as Lost Revenue Finding 2021-001 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 TIN #736060835 Federal Financ...

Consideration of Amounts Reported as Lost Revenue Finding 2021-001 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 TIN #736060835 Federal Financial Assistance Listing # 93.489 Finding Summary: The Medicare C revenue and total revenue for the first quarter of 2021 was overstated by $300,000 on the HRSA Period 2 report. The result did not affect the lost revenues calculated. Responsible Individuals: Richard Wagner, Chief Financial Officer Corrective Action Plan: The Authority has enhanced the internal controls to ensure underlying supporting records agree to the final reports submitted to HHS, including a review and approval by someone different than the individual inputting the report data. Anticipated Completion Date: April 2023

View Audit 42346

Finding 49588 (2022-001)

Significant Deficiency 2022

Impact Services Corporation

PA

Questioned Costs Reporting Significant Deficiency

Impact Services Corporation and Its? Consolidated Affiliates respectfully submits the following Corrective Action Plan for the year ended June 30, 2022. As audited by: Zelenkofske Axelrod LLC 2370 York Road, Suite A-5 Jamison, PA 18929 Audit Period: July 1, 2021 through June 30, 2022 The Significan...

Impact Services Corporation and Its? Consolidated Affiliates respectfully submits the following Corrective Action Plan for the year ended June 30, 2022. As audited by: Zelenkofske Axelrod LLC 2370 York Road, Suite A-5 Jamison, PA 18929 Audit Period: July 1, 2021 through June 30, 2022 The Significant Deficiency reported in the June 30, 2022 Schedule of Findings and Questioned Costs is discussed below. The significant deficiency applies to both the consolidated financial statements reported in accordance with Government Auditing Standards, issued by the Comptroller General of the United States and the Uniform Guidance, Title 2, U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. Recommendations: We recommend Impact ensure that financial records for all related entities are reconciled and closed on a monthly basis. Monthly financial statements, both individual entities and on a consolidated basis, should be provided to an analyzed by management and the Board of Directors. All financial information should be filed with funders, creditors, and the Federal Audit Clearinghouse in a timely manner. Corrective Action: Impact will take this recommendation and implement revised procedures to ensure timely month-end and year-end financial statements are provided to management, the Board of Directors, funders, creditors, and independent auditors. I, Michael Waterman, Chief Financial Officer, will be responsible for resolving this deficiency by October 1, 2023.

View Audit 42118

Finding 49587 (2022-002)

None 2022

Louisville Voa Elderly Housing, Inc. (south Oaks Senior Housing)

LA

Reporting Questioned Costs

Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The security deposit deficiency was funded on March 4, 2022 in the amount of $2,438. Management wi...

Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The security deposit deficiency was funded on March 4, 2022 in the amount of $2,438. Management will ensure that the security deposits are properly funded in the future. Completion Date: March 4, 2022

View Audit 42469

Finding 49586 (2022-001)

None 2022

Louisville Voa Elderly Housing, Inc. (south Oaks Senior Housing)

LA

Reporting Questioned Costs

Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The replacement reserve deficiency will be funded on in the amount of $10,480. Management will ens...

Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The replacement reserve deficiency will be funded on in the amount of $10,480. Management will ensure that the replacement reserve deposits are made on a timely basis in the future Completion Date: September 8, 2022

View Audit 42469

Finding 49574 (2022-013)

Significant Deficiency 2022

The Chosen Ones Outreach Ministries of Galveston, INC

TX

Questioned Costs

The Chosen Ones accounting department and Executive Director will develop processes and controls to monitor the receipt and spending of federal funds to ensure they are used within the grant requirements in a reasonable period in accordance with the contract. The Board of Directors and the Executiv...

The Chosen Ones accounting department and Executive Director will develop processes and controls to monitor the receipt and spending of federal funds to ensure they are used within the grant requirements in a reasonable period in accordance with the contract. The Board of Directors and the Executive Director will have monthly meetings to discuss the timeliness of spending these funds awarded in advance and this meeting will be documented in the form of minutes. Actual spending and receipt of funds will be documented in the form of a worksheet which the Executive Director and accounting personnel will develop for the Board Members to review and make inquiries where needed for items of concern.

View Audit 42319

Finding 49573 (2022-012)

Material Weakness 2022

The Chosen Ones Outreach Ministries of Galveston, INC

TX

Questioned Costs

The Chosen Ones accounting department and Executive Director will monitor spending for administrative costs by closely reviewing actual expenditures to budgets. All purchases will be required to have a pay request or purchase order approved by the Executive Director and one Board Member who will co...

The Chosen Ones accounting department and Executive Director will monitor spending for administrative costs by closely reviewing actual expenditures to budgets. All purchases will be required to have a pay request or purchase order approved by the Executive Director and one Board Member who will compare actual results of spending to the allowed budget with grants and budgets developed internally.

View Audit 42319

Finding 49572 (2022-011)

Material Weakness 2022

The Chosen Ones Outreach Ministries of Galveston, INC

TX

Questioned Costs

Management of the Chosen Ones will develop processes of controls to properly authorize new asset purchases, maintain those assets, track, and dispose of the assets by developing a unform policy for capitalization of assets over a specific threshold and logging them into an asset detail worksheet by ...

Management of the Chosen Ones will develop processes of controls to properly authorize new asset purchases, maintain those assets, track, and dispose of the assets by developing a unform policy for capitalization of assets over a specific threshold and logging them into an asset detail worksheet by notifying their auditor or accounting department of the new or disposed asset.

View Audit 42319 Questioned Costs: $1

Finding 49571 (2022-010)

Significant Deficiency 2022

The Chosen Ones Outreach Ministries of Galveston, INC

TX

Questioned Costs

The Chosen Ones accounting department and Executive Director will develop a process in which the audit will be completed in a timely manner to submit it to the FAC by hiring an auditor earlier in the year and submitting to the Clearing house within 30 days of the audit report or nine months after th...

The Chosen Ones accounting department and Executive Director will develop a process in which the audit will be completed in a timely manner to submit it to the FAC by hiring an auditor earlier in the year and submitting to the Clearing house within 30 days of the audit report or nine months after the Organization?s year end.

View Audit 42319

Finding 49570 (2022-009)

Material Weakness 2022

The Chosen Ones Outreach Ministries of Galveston, INC

TX

Questioned Costs

The Chosen Ones will develop processes to require payroll pay types related to training, hazard pay, and volunteer pay to be treated as employees of the Organization. The HR Manager will require these staff members or potential staff members to comply with HR Policies for documentation to be comple...

The Chosen Ones will develop processes to require payroll pay types related to training, hazard pay, and volunteer pay to be treated as employees of the Organization. The HR Manager will require these staff members or potential staff members to comply with HR Policies for documentation to be completed and obtained and will supply all timecards to keep track of their time for services. These timecards will be submitted for approval prior to payment by having the Executive Director and one Board Member review and approve the timecards. All volunteer pay will be monitored to ensure the pay meets all requirements with regulations for federal and state tax requirements. Each volunteer will be required to keep track of their time and turn it in for review and approval by the Executive Director and one board member prior to payment being authorized. The Executive Director will refrain from drawing cash out of the checking account and using the funds to purchase gift cards to pay volunteers for their services.

View Audit 42319 Questioned Costs: $1

Finding 49569 (2022-008)

Significant Deficiency 2022

The Chosen Ones Outreach Ministries of Galveston, INC

TX

Questioned Costs

The Chosen Ones accounting department and Executive Director will develop a process to ensure that all funding requests submitted to the TDHCA system are applied for within the specific period?s due date. Actual spending or budgeted amounts will be documented using a worksheet or memorandum from th...

The Chosen Ones accounting department and Executive Director will develop a process to ensure that all funding requests submitted to the TDHCA system are applied for within the specific period?s due date. Actual spending or budgeted amounts will be documented using a worksheet or memorandum from the accounting department and reviewed and approved by the Executive Director and One Board member prior to submittal and proof of the submittal will be attached to this packet. Each packet will have copies of checks, invoices, and application packets for which the funds are being applied for.

View Audit 42319

Finding 49568 (2022-007)

Material Weakness 2022

The Chosen Ones Outreach Ministries of Galveston, INC

TX

Questioned Costs

The Chosen Ones accounting department, Executive Director, and Board Members will develop processes to ensure reconciliation procedures for actual expenditures are reviewed and that this review is documented by means of a worksheet, memo, or other form of measurement to ensure the funds which are ap...

The Chosen Ones accounting department, Executive Director, and Board Members will develop processes to ensure reconciliation procedures for actual expenditures are reviewed and that this review is documented by means of a worksheet, memo, or other form of measurement to ensure the funds which are applied for are matched to the appropriate revenue to be recognized and to the TDHCA system.

View Audit 42319

Finding 49561 (2022-004)

Material Weakness 2022

Dundee Community Schools

MI

Allowable Costs / Cost Principles Questioned Costs

2022-004 ? Documentation and Internal Controls over Journal Entries Auditor Description of Condition and Effect. Evidence of an independent review was not documented for eight out of the eight journal entries selected for testing. The District is at increased risk of unallowable costs being charged...

2022-004 ? Documentation and Internal Controls over Journal Entries Auditor Description of Condition and Effect. Evidence of an independent review was not documented for eight out of the eight journal entries selected for testing. The District is at increased risk of unallowable costs being charged to federal programs without being detected by its internal controls. Auditor Recommendation. We recommend the District follow its internal control policies and procedures that require independent review of all journal entries. Responsible Person: Sharon Ramirez, Chief Financial Officer Corrective Action. Management concurs with the finding. Anticipated Completion Date: June 30, 2023

View Audit 42306

Finding 49559 (2022-002)

Material Weakness 2022

South Limestone Hospital District D/b/a Limestone Medical Center

TX

Questioned Costs Reporting Internal Control / Segregation of Duties

We are in receipt of the Finding Required to be Reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete ...

We are in receipt of the Finding Required to be Reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls by introducing additional oversight and review for future COVID-19 Provider Relief Fund reporting. Larry Price, CEO, will be responsible to ensure this is accomplished. The District had enough expenditures for Period 2 and 3 funding received so that no lost revenues were utilized as a basis for the funds received. The corrective action plan will be implemented by September 30, 2023.

View Audit 42405

Finding 49534 (2022-009)

Significant Deficiency 2022

County of Kern

CA

Questioned Costs Allowable Costs / Cost Principles Reporting

Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: CLA recommends the County to work with department to provide training over understanding the grant agreement. As well as further reviewing the programs that received COVID funding when compiling the SEFA. Expla...

Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: CLA recommends the County to work with department to provide training over understanding the grant agreement. As well as further reviewing the programs that received COVID funding when compiling the SEFA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor-Controller?s Office is working with departments to improve SEFA reporting and has recommended individuals who work with grants to attend annual cost principles training. Name(s) of the contact person(s) responsible for corrective action: Aimee Espinoza, Auditor-Controller and Tarrah Shockley, Division Chief. Planned completion date for corrective action plan: June 30, 2023

View Audit 43375

Finding 49532 (2022-001)

Material Weakness 2022

Indiana University Health, Inc. and Subsidiaries

IN

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

IU Health designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports. These internal controls were precise enough to ensure that the submissions were compliant with HRSA reporting guidance. In fact, IU Health reached out directly to...

IU Health designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports. These internal controls were precise enough to ensure that the submissions were compliant with HRSA reporting guidance. In fact, IU Health reached out directly to HRSA to confirm the appropriateness of its election. IU Health remained consistent in utilizing the annual budget as a basis for lost revenue past 2020. As inferred from the annual budget approval date threshold of March 27, 2020, our 2021 and 2022 budgets were prepared using prepandemic years as a baseline expectation. IU Health also conversed directly with HRSA wherein a representative confirmed our use of option 2 as appropriate for Period 3 and beyond, because, according to the representative, the intention of the written regulation did not literally mean budget approval for years past 2020 to have occurred prior to March 27, 2020. As our annual budgets were already naturally materially in line with our long-range plan that was approved in December of 2019, it seemed we were adhering to the spirit of the guidelines set forth. For future periods, IU Health will elect option 3 for lost revenue. Contact Person(s) Responsible for Corrective Action: David Burton Anticipated Completion Date: Effective for Period 5 deadline of September 30, 2023

View Audit 43374

Finding 49530 (2022-004)

Material Weakness 2022

Western Michigan University

MI

Matching / Level of Effort / Earmarking Questioned Costs Material Weakness § 200.328 § 200.329

Finding Number: 2022-004 Condition: The University did not file accurate and timely reports throughout the fiscal year. Planned Corrective Action: 1. The 9/30/21 HEERF institutional report was posted on the University?s website 10 days late. This was due to the staff member responsible going out...

Finding Number: 2022-004 Condition: The University did not file accurate and timely reports throughout the fiscal year. Planned Corrective Action: 1. The 9/30/21 HEERF institutional report was posted on the University?s website 10 days late. This was due to the staff member responsible going out on medical leave and miscommunication within the area on required filings. There were no additional quarterly reports to be filed so no further controls were put in place for this reporting. The annual report was filed timely. 2. The 9/30/21 institutional report has been removed from the University website as it indicated a duplicate expense that was reported on the 6/30/21 quarterly report. The 06/30/21 report has been marked as the final institutional report. 3. The Student Financial Aid (SFA) office agrees that the March 31, 2022, student website report did not include language regarding eligible students, and the reported student count was incorrect. SFA will amend the March 31, 2022, quarterly student report to reflect the correct number, add language regarding eligible students, and send the correction to the appointed HEERF email address by June 1, 2023. The Associate Director of Compliance and Training will perform a secondary review of any future reports to ensure the completeness and accuracy of the information. 4. The Student Financial Aid (SFA) office agrees that the 2021 annual report included the incorrect number of part-time graduate students who received an award, impacting the total number of students reported. The error was due to incorrectly inputting the information from the supporting data onto the annual report. SFA will amend the 2021 annual report by correcting the number of part-time graduate students by March 24, 2023. The Associate Director of Compliance and Training will perform a secondary review of the data on the annual report and compare it with the supporting documentation. 5. As indicated in the report, the University did comply with earmarking requirements. However, the categories used to report the expenditures on the 12/31/21 annual report were not the specific earmarked categories. The 12/31/21 annual report filed through the Department of Education website has just recently been made active again and the University will make necessary category reporting corrections. As the 12/31/21 annual report was the final report for institutional expenses no additional actions are required. Contact person responsible for corrective action: Colleen Scarff, Assoc VP for Business and Finance and Lana Greaves, Senior Associate Director, Student Financial Services Anticipated Completion Date: 3/24/23

View Audit 47967

Finding 49520 (2022-003)

Material Weakness 2022

Western Michigan University

MI

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

Finding Number: 2022-003 Condition: The University did not return funds in accordance with 34 CFR 668.22 which states, when a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the inst...

Finding Number: 2022-003 Condition: The University did not return funds in accordance with 34 CFR 668.22 which states, when a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of Title IV aid earned by the student as of the student?s withdrawal date. If the total amount of Title IV assistance earned by the student is less than the amount that was disbursed to the student or on his or her behalf as of the date of the institution?s determination that the student withdrew, the difference must be returned to the Title IV programs. Planned Corrective Action: The Student Financial Aid (SFA) office agrees with the finding that all the funds calculated to be returned for a student were not billed back. Management acknowledges that the deficiency was due to an oversight. The isolated occurrence was corrected on 01-13-2023. The unsubsidized loan amount of $3,558 was returned, and the change was reflected in COD. SFA awarded the student institutional aid of $3,558 to compensate for the error. In addition, the 60% withdrawal date was corrected, R2T4 calculations were performed, the funds were returned, and SFA awarded the students institutional aid to compensate for the errors. Step-by-step procedure for calculating the R2T4 60% withdrawal date were created and before the beginning of each aid year, Client Services and the Associate Director of Compliance will determine the 60% withdrawal dates for each term. Contact person responsible for corrective action: Lana Greaves, Senior Associate Director, Student Financial Services Anticipated Completion Date: 04/15/2023

View Audit 47967 Questioned Costs: $1

Finding 49519 (2022-002)

Material Weakness 2022

Western Michigan University

MI

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

Finding Number: 2022-002 Condition: The University initiated certain returns of Title IV funds after the required timing. Planned Corrective Action: The Student Financial Aid (SFA) office agrees with the finding that certain Return of Title IV funds were initiated after the required time. SFA evalua...

Finding Number: 2022-002 Condition: The University initiated certain returns of Title IV funds after the required timing. Planned Corrective Action: The Student Financial Aid (SFA) office agrees with the finding that certain Return of Title IV funds were initiated after the required time. SFA evaluated its R2T4 procedures in May 2022 and strengthened its internal controls by: 1. Reviewing reports of withdrawn students on a daily basis. 2. Weekly reporting of R2T4 and LDA students and calculations with two levels of approvals. 3. Holding weekly meetings and performing self-assessments to verify completion and accuracy of R2T4 calculations. Contact person responsible for corrective action: Lana Greaves, Senior Associate Director, Student Financial Aid Anticipated Completion Date: 10/23/2022

View Audit 47967

Finding 49472 (2022-005)

Material Weakness 2022

Dartmouth-Hitchcock Health and Subsidiaries

NH

Eligibility Questioned Costs Subrecipient Monitoring

Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: T1081685 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2021 - 2022 Pass-through entity: NH ...

Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: T1081685 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2021 - 2022 Pass-through entity: NH Dept of Health and Human Services Management understands and agrees that there was a failure to follow the documentation requirements of the Opioid STR award during the majority of the time period covered by the audit. In June 2022 the Doorway began implementing a screening tool used at the time of patient intake to determine which patients are eligible under the grant. Additionally, a process will be implemented to perform the required income reassessments every 4 weeks and to track time and differentiate costs between eligible and non-eligible patients. Any patient deemed ineligible in the initial screening or subsequent four week reassessments will continue to be treated, but the associated cost will not be charged to the grant. This documentation will be reviewed a minimum of two times per year by Cheshire?s Compliance Manager, and more frequently if errors are found. Results will be reported to the Chief Operating Officer and the Chief Financial Officer Cheshire has implemented a separation of duties where the clinic administrator will ensure and maintain appropriate documentation, while a senior finance analyst will review and verify appropriateness prior to invoicing the grant. This process will add an additional check to be certain only eligible patients are charged to the grant. Leadership Responsible: Daniel Gross, Chief Financial Officer ? Cheshire Medical Center Anticipated Completion Date: 9/30/2023

View Audit 42417 Questioned Costs: $1

Corrective Action Plans

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