Corrective Action Plans

Finding 548009 (2024-009)

Significant Deficiency 2024

MA

Eligibility Reporting

Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that all participant information is retained and for management to perform and document periodic reviews of eligibility...

Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that all participant information is retained and for management to perform and document periodic reviews of eligibility determinations. As required to maintain the Organization’s Pending Recognition status with the Diabetes Prevention Recognition Program (DPRP), Quincy Asian Resources, Inc. has complied with all data collection and reporting requirements.

View Audit 351904

Finding 548001 (2024-001)

Significant Deficiency 2024

Quincy Asian Resources, Inc.

MA

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding, we want to emphasize our review indicates all transactions were handled with appropriate intent. The identified adjustments were primarily due...

Views of Responsible Officials and Planned Corrective Action: While Quincy Asian Resources, Inc. concurs with the ultimate outcome identified in the finding, we want to emphasize our review indicates all transactions were handled with appropriate intent. The identified adjustments were primarily due to timing of personnel transitions on our accounting department. To further strengthen our financial reporting processes, we have subsequently hired a new controller with extensive nonprofit accounting experience. This addition to our team will help ensure continued accuracy in financial reporting while maintaining strong internal controls.

View Audit 351904

Finding 547987 (2024-003)

Material Weakness 2024

Umpqua Public Transportation District

OR

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

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

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

View Audit 351895

Finding 547985 (2024-101)

Material Weakness 2024

Maricopa County

AZ

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.303

Concur: The Maricopa County Human Services Department will update its procedures involving subaward actions as required by FFATA and Federal Uniform Guidance. These internal procedures will include reporting subaward actions equaling or exceeding more than $30,000 no later than month-end following t...

Concur: The Maricopa County Human Services Department will update its procedures involving subaward actions as required by FFATA and Federal Uniform Guidance. These internal procedures will include reporting subaward actions equaling or exceeding more than $30,000 no later than month-end following the subaward action. Additionally, the Department has updated all tracking listings and will ensure all grants contracted through other departments and amendments are included. On February 27, 2025, the Department completed and submitted the required FFATA form to USAspending.gov.

View Audit 351894

Finding 547981 (2024-003)

Significant Deficiency 2024

Nuestra Escuela

PR

Reporting Internal Control / Segregation of Duties

Management response: • Nuestra Escuela’s Program Director will adopt automated data collection software to ensure the timely availability of participants information, thereby preventing delays in report submission. • Nuestra Escuela will enhance its internal controls to ensure adherence to all req...

Management response: • Nuestra Escuela’s Program Director will adopt automated data collection software to ensure the timely availability of participants information, thereby preventing delays in report submission. • Nuestra Escuela will enhance its internal controls to ensure adherence to all required reporting deadlines, promoting timely and accurate submissions under the TANF program strengthen internal controls to ensure the compliance with the reporting. • Nuestra Escuela will conduct regular audits to verify data accuracy, maintaining open and consistent communication with all relevant parties to address potential reporting bottlenecks. • Nuestra Escuela Management staff will receive specialized training on participant qualification and proper requirements and efficient time management practices to improve reporting compliance. • The Executive President will develop and implement a contingency plan to address unforeseen circumstances that could otherwise hinder timely submission of reports. Corrective action plan: Action Date of Compliance Involved areas Adopt automated data collection software Jun 25 - 2025 Executive President Program Director Schedule of internal monitoring for compliance with Special Conditions Monthly Program Director Specialized training on participant qualification and proper requirements May 22 - 2025 External Consultant Program Director Directors in charge of Programs Develop a contingency plan to address unforeseen circumstances Apr 10 - 2025 Executive President External Consultant Actions to complete monthly: ● Internal monitoring by the Program Director with the automated data collection software. ● Meeting between the Program Director and the Directors of each of the Programs to validate the correct status of the reports. Actions to complete quarterly: ● Meeting between the Program Director and the Executive President for a physical review of the files. Contact Person: Ana Yris Guzmán – Executive President|

View Audit 351891

Finding 547968 (2024-002)

Significant Deficiency 2024

Nuestra Escuela

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2...

Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. • The accounting staff will undergo specialized training on the proper recognition of conditional advances. Regular reviews will be conducted to ensure ongoing compliance with ASU 2018-08 and to maintain accurate financial reporting. • Recognizing the need to meet both agency (cash basis) and GAAP (accrual basis), Nuestra Escuela will prepare management reports on both bases. This approach will facilitate accurate grant reporting while ensuring compliance with generally accepted accounting principles. Corrective action plan: Action Date of Compliance Involved areas Developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Apr 21 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Create a “Model reports” on both bases, to use monthly. Monthly Executive President Administrative Director Specialized training on the proper recognition of conditional advances. Jun 10 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Actions to complete monthly: • To prepare management reports on both bases Actions to complete quarterly: • Use the rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Contact Person: Ana Yris Guzmán – Executive President

View Audit 351891

Finding 547967 (2024-001)

Significant Deficiency 2024

Nuestra Escuela

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to...

Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to detect, identify, and correct, any discrepancies that may indicate cut-off errors. • The administrative staff and accounting team will receive additional training on the best practices and proper cut-off procedures, emphasizing the importance of timely and accurate recognition of liabilities and receivables and the impact of errors on financial reporting. • Nuestra Escuela will reinforce its internal audit processes to periodically review compliance with cut-off procedures. This practice will involve analyzing the impact of contractual clauses on the period of receipt and use of funds. • Nuestra Escuela will Create documentation of its cut-off policies and procedures to ensure consistent application and understanding among all relevant staff and ensure that they are strictly enforced. • Nuestra Escuela is committed to preventing cut-off errors through a proactive approach from accountants. This involves a combination of robust procedures, leveraging technology, and fostering a culture of accuracy and compliance within the accounting department. By following these best practices, accountants can help ensure the integrity of the financial reporting process. Corrective action plan: Action Date of Compliance Involved areas Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Monthly Executive President Administrative Director Analyze the impact of contractual clauses on the period of receipt and use of funds. Apr 15 – 2025 Jul 15 -2025 Oct 15 – 2025 Ene 15 - 2026 Executive President Administrative Director Training on the best practices and proper cut-off procedures May 8 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Complete file with cut-off policies and procedures Jun 20 - 2025 Administrative Director Directors in charge of Programs Actions to complete monthly: • Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Actions to complete quarterly: • Analyze the impact of contractual clauses on the period of receipt and use of funds. • Training on the best practices and proper cut-off procedures • Complete file with cut-off policies and procedures Contact Person: Ana Yris Guzmán – Executive President

View Audit 351891

Finding 547966 (2024-003)

Material Weakness 2024

Community Action Partnership of Mercer County

PA

Questioned Costs Cash Management Reporting

Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for a...

Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for all journal entries made to the program to ensure that amount charged to the program are actual expenses/expenditure of the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025

View Audit 351890 Questioned Costs: $1

Finding 547964 (2024-001)

Material Weakness 2024

Community Action Partnership of Mercer County

PA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.403

Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Goi...

Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Going forward, the Organization will review all vouchers being charged to the program to make sure costs have been incurred before being charged to the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025

View Audit 351890 Questioned Costs: $1

Finding 547950 (2024-009)

Material Weakness 2024

State of Hawaii Department of Health

HI

Subrecipient Monitoring Reporting

Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating...

Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division

View Audit 351885

Finding 547947 (2024-006)

Material Weakness 2024

State of Hawaii Department of Health

HI

Reporting § 200.327

Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS s...

Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division

View Audit 351885

Finding 547946 (2024-005)

Material Weakness 2024

State of Hawaii Department of Health

HI

Subrecipient Monitoring Reporting

Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to ...

Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: April 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division

View Audit 351885

Finding 547937 (2024-002)

Significant Deficiency 2024

New River Health Association, Inc.

WV

Procurement, Suspension & Debarment HUD Housing Programs Reporting

Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization con...

Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025

View Audit 351868

Finding 547935 (2024-003)

Significant Deficiency 2024

Clackamas County, Oregon

OR

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us...

Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, and oversight. These will include: • Departments will ensure that all expenses are reviewed to confirm alignment with the specific terms and conditions of the grant before reallocating any charges. • Redistribution of Award expenses will be reviewed and approved by Division Director and/or Finance Grant Manager • Federal Awards quarterly reporting will be reviewed and approved by Finance Grant Manager prior to submission • Journal Entries will be for correcting entries and not move funded expenditures to other funding revenues • All Journal Entries will have complete supporting documentation reviewed and signed by Director level staff at the Division or by Finance Grant Management Anticipated Completion Date: Implementation of controls by March 24, 2025.

View Audit 351867

Finding 547928 (2024-001)

Significant Deficiency 2024

Clackamas County, Oregon

OR

Subrecipient Monitoring Reporting

Finding 2024-001: Reporting – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-9...

Finding 2024-001: Reporting – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, oversight, and record retention related to reporting of subawards greater or equal to $30,000. These will include: • Timely monitoring for the status of FFATA subaward reporting • Receive the FFATA subaward report to SAM.gov confirmation from Sub Recipient contractor • Retain documentation of submission to SAM.gov • Include quarterly cash-on-hand reports to award checklist to be completed in the Finance office • Compile listing of current open subrecipient agreements for adherence to FFATA contractor award reporting to ensure compliance Anticipated Completion Date: Implemented as a control to the Finance Grant checklist for each award March 20, 2025.

View Audit 351867

Finding 547925 (2024-002)

Material Weakness 2024

Local Area Workforce Development South Central

PR

Material Weakness Reporting Internal Control / Segregation of Duties

We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive...

We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director

View Audit 351865

Finding 547920 (2024-003)

Significant Deficiency 2024

Boys and Girls Clubs of Philadelphia, Inc.

PA

Allowable Costs / Cost Principles Cash Management Period of Performance

View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting ...

View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder and the funder will not seek to recoup out of period costs. Moving forward, the Organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year

View Audit 351859

Finding 547918 (2024-001)

Significant Deficiency 2024

Catholic Community Services of Southern Arizona, Inc.

AZ

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Cash Management

CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest an...

CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest and Procurement procedures. Conflict-of-Interest and procurement policy training sessions were conducted with all levels of staff and will continue to be conducted on a recurring basis. CCS is implementing additional layers of oversight and compliance monitoring. This is the responsibility of the CCS Chief Financial Officer. CCS is committed to continuous improvement, conducting regular internal audits and reviews to verify adherence to federal procurement standards. This is the responsibility of the CCS Revenue Cycle Manager. We are working to ensure that every vendor has a contract on file and all procurement policies are strictly followed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.

View Audit 351857

Finding 547917 (2024-003)

Significant Deficiency 2024

Emory & Henry College

VA

Student Financial Aid Reporting Special Tests & Provisions

2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set f...

2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR Section 685.309(b)(2), the College is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The College does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Context: From a population of 26 students that withdrew officially and unofficially during a term, we tested 3 students and noted those students’ withdrawals were not reported timely or accurately. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Recommendation: We recommend that a review process be put in place to ensure timely and accurate enrollment reporting to NSLDS and additional training on the reporting requirements as needed. Management Response: Management is working with the Registrar’s Office to determine why there was an issue and provide a process that will eliminate any untimely reporting to Clearinghouse moving forward. If the Federal Audit Clearinghouse has questions regarding this plan, please call Angie Edmondson, CFO, 276-944-6755, aedmonds@emoryhenry.edu

View Audit 351842

Finding 547884 (2024-007)

Significant Deficiency 2024

Blackburn University Dba Blackburn College

IL

Questioned Costs Special Tests & Provisions Student Financial Aid

Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students ...

Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students stopped engaging academically • Verify whether R2T4 calculations should have been performed Corrective Actions • Process R2T4 calculations for affected students based on their last date of attendance • Return any unearned Title IV funds • Update students file to reflect accurate withdrawal dates and notify them of any financial obligations resulting from the adjustment • If students are still enrolled in future terms, ensure they understand satisfactory academic progress (SAP) implications Process and Policy Improvements • Implement an early alert system to identify students who cease attendance before the end of the term. • Strengthen collaboration between academic departments, the registrar, and the financial aid office to improve withdrawal tracking • Run monthly withdrawal reports to see when students earn all failing grades. Monitoring and Compliance • Conduct regular audits to ensure compliance with R2T4 regulations and timely student withdrawals • Provide staff training on withdrawal procedures and the importance of accurately tracking last dates of attendance. • Establish a set time to review withdrawal policies and ensure adherence to federal regulations. Reporting and Documentation • Maintain detailed records of all identified cases, R2T4 calculations, and funds returned. • Document all policy and procedural updates made to prevent recurrence. • If required, submit a report to the U.S. Department of Education outlining corrective actions taken. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25

View Audit 351835 Questioned Costs: $1

Finding 547883 (2024-006)

Significant Deficiency 2024

Blackburn University Dba Blackburn College

IL

Reporting Special Tests & Provisions Student Financial Aid

Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting d...

Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting delays or errors, whether due to system malfunctions, manual processing errors, or lack of oversight Corrective Actions • Submit corrected enrollment data to NSLDS for all affected students using our National Student Clearinghouse. • Ensure that all errors identified during the audit are addressed, and follow up to confirm the corrections are reflected in NSLDS. • Notify any impacted students of any changes in their enrollment status and provide necessary support if their loan repayment terms are affected. Process and Policy Improvements • Develop and implement clear policies to ensure accurate and timely submission of enrollment data within the required 30-day reporting window or in accordance with scheduled reporting intervals. • Automate the enrollment reporting process where possible to minimize manual data entry errors. • Establish cross-departmental communication protocols to ensure timely updates on student withdrawals, graduations, and status changes. • Create detailed documentation of reporting procedures for staff training and compliance purposes. Monitoring and Compliance • Implement regular reconciliation checks between our student information system (SIS) and NSLDS to ensure data accuracy • Conduct periodic internal audits to identify discrepancies before external audits occur • Designate staff to oversee enrollment reporting and ensure adherence to federal regulations. Staff Training • Provide comprehensive training for staff responsible for enrollment reporting on NSLDS requirements, deadlines, and best practices • Offer training sessions as regulations change or system updates occur. Reporting and Documentation • Maintain records of all corrected data submissions, audit results, and communications with NSLDS • Document procedural changes and staff training efforts Responsible Person for Correction Action Plan: Dianna Ruyle, Director of Records, Registration and Advising Implementation Date for Corrective Action Plan: Immediately and ongoing

View Audit 351835

Finding 547783 (2024-004)

Material Weakness 2024

Rural Resources Community Action

WA

Subrecipient Monitoring Material Weakness Reporting

FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a re...

FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submitted timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller

View Audit 351833

Finding 547745 (2024-003)

Significant Deficiency 2024

Rural Resources Community Action

WA

Reporting Internal Control / Segregation of Duties Significant Deficiency

FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control sur...

FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submited timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller

View Audit 351833

Finding 547731 (2024-011)

Material Weakness 2024

County of Orange, California

CA

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.303 § 200.510

2024-011 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 Compliance Requireme...

2024-011 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 Compliance Requirements: Other - Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria: In accordance with the 2024 OMB Compliance Supplement, nonfederal entities must record expenditures on the Schedule of Expenditures of Federal Awards (SEFA) when (1) FEMA has approved the nonfederal entity’s Project, and (2) the nonfederal entity has incurred the eligible expenditures. FEMA’s approval of a subaward is indicated when FEMA obligates the federal share of the eligible project cost to the recipient. Federal awards expended in years subsequent to the fiscal year in which the Project is approved are to be recorded on the nonfederal entity’s SEFA in those subsequent years. In addition, section 200.303 of the Uniform Guidance states that recipients and subrecipients must establish effective internal control over the federal awards, including controls over the accuracy of program information and expenditure amounts. Condition: During our audit procedures performed over the Schedule of Expenditures of Federal Awards and expenditures reported for the Disaster Grants – Public Assistance (Presidentially Declared Disasters) we noted the County reported expenditures totaling $5,820,436 that should have been reported on the FY 2023 SEFA, as the granting agency approved the expenditures in FY 2023 and the County incurred the expenditures prior to June 30, 2023. Cause: The County lacks adequate internal controls to ensure the SEFA is completely and accurately stated. Effect: The initial FY 2024 SEFA provided was overstated by $5,820,436. However, we noted these expenditures would not have had a material effect on the FY 2023 SEFA. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. Program expenditures on the SEFA were reconciled to supporting records. Repeat Finding from Prior Years: No. Recommendation: We the recommend that the County establish policies and implement internal controls to ensure that expenditures are reported on the SEFA in accordance with program requirements. Management Response and Corrective Action: 1. Person Responsible: Trevor Richardson, OCPW Emergency Manager 2. Corrective Action Plan: Due to the change in reporting guidance, we will now report the full amount of the award in the fiscal year it is approved, based on the obligation letter, instead of on a cash basis. 3. Anticipated Implementation date: Effective immediately for FY24-25.

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Finding 547730 (2024-010)

Significant Deficiency 2024

County of Orange, California

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance ...

2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: For two (2) out of three (3) project application summary reports tested, the OCPW did not retain evidence to document the individual who reviewed and approved the required reports. Cause: The department’s procedures did not include documenting the review and approval of the reports prior to submission. Effect: Ineffective controls over this area of compliance could result in reports that are inaccurate or incomplete being submitted or disclosed to the granting agency. Questioned Costs: No questioned costs were identified as a result of our audit procedures. Context/Sampling: A non-statistical sample of three (3) of nine (9) Grant Project Application Summary Reports were selecting for testing. The condition above was identified during our procedures over reporting testing. Repeat Finding: No. Recommendation: We recommend the OCPW department revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. Management Response and Corrective Action: 1. Person Responsible: • FEMA Public Assistance Grants Coordinator – Responsible for completing reports, uploading documents to the FEMA Grants Portal, and ensuring accurate records. • OCPW Emergency Manager Responsible for reviewing, approving, and submitting project applications. 2. Corrective Action Plan: • Revised Procedures for Review and Approval: i. The FEMA Public Assistance Grants Coordinator will be responsible for completing the Project Application Summary Reports. ii. Upon completion, the Grants Coordinator will upload all supporting documents into the FEMA Grants Portal. The system automatically timestamps each document and records the name of the individual who uploaded it, ensuring clear documentation of the review process. iii. After all required documents are uploaded, the OCPW Emergency Manager will be notified that the project application is ready for review. iv. The OCPW Emergency Manager will then: 1. Review the submitted documents in the FEMA Grants Portal. 2. Confirm that the reported costs align with the information provided by the reporting County agency. 3. Approve and submit the project application to Cal OES and FEMA for project approval. • Retention of Documentation: i. The FEMA Grants Portal serves as the official system of record, ensuring all uploaded documents are timestamped and traceable. ii. All project application approvals, cost documentation, and required forms will be retained electronically within the system for audit and compliance purposes. • Training and Implementation: i. Staff responsible for grant reporting will receive training on the revised process, including proper document upload procedures and compliance expectations. ii. The updated process will be implemented immediately. • Monitoring and Compliance: i. The OCPW Emergency Manager will conduct semiannual internal reviews of project applications to ensure compliance with the updated procedures. ii. Any issues identified during internal reviews will be addressed through additional staff training and process improvements. 3. Anticipated Implementation date: Immediate, March 18, 2025 • Staff Training: Within 30 days • Semiannual Compliance Review: Beginning next quarter i. First review will take place May 1, 2025. Followed by another review in October 2025.

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Corrective Action Plans

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