Corrective Action Plans

Finding 390379 (2023-104)

Material Weakness 2023

Coconino County

AZ

Reporting Internal Control / Segregation of Duties § 200.303

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completi...

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration department acknowledges the required financial reports were not all submitted during FY23. The Department did not have a tracking mechanism in place to ensure that all staff were aware of the status of report submission. Additionally, due to recent turnover, the Department did not have staff trained to complete the reports. The Department will complete and submit missing federal financial reports according to the direction provided by the Arizona Department of Economic Security. The County will ensure that the staff responsible for grant reporting have the knowledge and skills necessary to do so in compliance with federal requirements and grant accounting practices. The County has implemented a mechanism to monitor and track reporting due dates and oversee reports to ensure accuracy.

View Audit 301196

Finding 390376 (2023-101)

Material Weakness 2023

Coconino County

AZ

Internal Control / Segregation of Duties Reporting § 200.301 § 200.302 § 200.303

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual fi...

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual financial and performance reports were not filed in accordance with the contract. The cash draw reports were completed for the award according to the contractual requirements. Therefore, the federal agency was aware of all expenditures made under the award. The FCD will submit all missing annual financial and performance reports. With assistance from the Finance Department, the FCD will develop procedures to ensure all reporting requirements are met. These procedures will include internal timelines, designated roles and responsibilities, and a tracking mechanism. Additionally, fiscal capacity will be created through the training of an additional staff member in reporting to serve as backup so contractual reporting requirements can be fulfilled when unforeseen challenges arise such as declared emergencies and flood events.

View Audit 301196

Finding 390374 (2023-002)

Material Weakness 2023

Collins Career Center

OH

Reporting Matching / Level of Effort / Earmarking § 200.329

I was instructed by our U.S. Department of Education representative to not post additional reports to our website until all prior reports have been corrected.

View Audit 301193

Finding 390368 (2023-007)

Material Weakness 2023

City of Amsterdam, New York

NY

Reporting Internal Control / Segregation of Duties Cash Management

The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary p...

The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary parties. A draft SEFA worksheet will be created and updated on an ongoing basis throughout the fiscal year. This will improve the accuracy of internal federal award data. Louise Biron will be responsible for this finding and the anticipated completion date is June 30, 2024.

View Audit 301192

Finding 390345 (2023-002)

Material Weakness 2023

Hawaii Pacific University

HI

Reporting § 200.328 § 200.329

The university endeavors to follow all applicable reporting regulations and guidance mandated for federally funded grant and contract programs. The HEERF awards were fully expended as of June 30, 2022 for the Student Portion and as of September 30th, 2022 for the Institutional Portion. Should simila...

The university endeavors to follow all applicable reporting regulations and guidance mandated for federally funded grant and contract programs. The HEERF awards were fully expended as of June 30, 2022 for the Student Portion and as of September 30th, 2022 for the Institutional Portion. Should similar programs become available in the future, management will develop, in advance of expending funds, documented policies and procedures to administer the program and will maintain documentation demonstrating compliance with program requirements and related institutional policy and procedure. Specifically for the HEERF program that has ended, the university will amend relevant Quarterly report(s) and submit an Annual Report for 2022, as required and in consultation with the Department of Education on reporting timelines and processes for amended reports. Reviews will be completed and documentation retained as described below. For future programs, the Office of Sponsored Projects will monitor available published information from the funding agency(ies) to ensure the university offices responsible for any element of the reporting process are aware of applicable deadlines and requirements. The Office of Sponsored Projects and the Office of Financial Aid will prepare required reports for institutional and student grant-related activity, respectively. These reports will be reviewed by the Office of Financial Aid (for any student portion) and the Office of Institutional Research and the Business Office (for all portions, including any institutional funds). These offices will collaborate to implement a review procedure to ensure the reports are accurate, complete, submitted timely, and if required, posted publicly to the university’s website. Additionally, files will be maintained in a shared location so that documentation is available in the event of turnover, so that support availability (including detail support) withstands any changes in the employment of the employees responsible for preparing, reviewing, and/or posting the reports. Persons Responsible: Assistant VP for the Office of Sponsored Projects; Director of Financial Aid; Controller and Associate Vice President. Targeted Correction Date: September 30th, 2024. Fiscal Year in which Finding Initially Occurred: 2021 (Finding Number 2021-003).

View Audit 301190

Finding 390307 (2023-002)

Significant Deficiency 2023

University of Massachusetts Global-9 Month Audit

CA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

University of Massachusetts Global concurs with this finding. The University utilizes the services of National Student Clearinghouse to report student status data to the NSLDS. There were 6 students reported as graduated beyond the 60 days, and 1 student with an error that was not corrected within 1...

University of Massachusetts Global concurs with this finding. The University utilizes the services of National Student Clearinghouse to report student status data to the NSLDS. There were 6 students reported as graduated beyond the 60 days, and 1 student with an error that was not corrected within 10 days. To address this, the Office of the Registrar now has access to NSLDS to ensure that what is reported to NSC is also updated accurately in NLSDS. The Office of the Registrar will also change the reporting dates so that it best aligns with the conferral dates. In addition, the Office of the Registrar will have an additional QA process so that any time status changes are compared against the NSC report that is generated and submitted.

View Audit 301167

Finding 390287 (2023-013)

Significant Deficiency 2023

Commonspirit Health

IL

Procurement, Suspension & Debarment Eligibility Reporting § 200.303

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Manageme...

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Management did not consistently retain evidence to support that internal controls were in place and operating effectively for approval of invoices with purchase orders and to ensure that bonuses paid to employees related to COVID-19 were eligible to receive the bonus. Corrective Action Plan: This program has ended. CHIC has no additional funding to apply expenses to.

View Audit 301158

Finding 390276 (2023-010)

Significant Deficiency 2023

Commonspirit Health

IL

Special Tests & Provisions Eligibility Reporting § 200.303

REFERENCE: 2023-010 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Tech...

REFERENCE: 2023-010 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science and CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Corrective Action Plan: This finding has been corrected for Good Samaritan as of April 2023. Enrollment reporting to the National Student Clearinghouse is conducted 5 times per year and reconciled monthly with loan borrowers to ensure active enrollment. Additional Status Update: The Dean of Enrollment Management validates and reports to the oversight committee regarding the monthly reporting. Monthly reporting to the GSC Compliance committee has verified completion since May 2023 and has been timely thereafter. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science David Velasquez, Nuclear Medicine Technologist Coordinator, CHI Health School of Radiologic Technology Expected Completion: April 2023 (Good Samaritan) and June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390273 (2023-006)

Material Weakness 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radi...

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan origination and disbursement records to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management for presentation to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science and Financial Aid Services (FAS) David Velasquez, Nuclear Medicine Technologist Coordinator (CHI Health School of Radiologic Technology) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390271 (2023-011)

Material Weakness 2023

Commonspirit Health

IL

Reporting § 200.303 § 200.502 § 200.510

REFERENCE: 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation SFA Cluster (Assistance Listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Management did not have effective int...

REFERENCE: 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation SFA Cluster (Assistance Listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted in an overstatement of the SEFA expenditures reported in the SEFA. Corrective Action Plan: This finding has been corrected. Good Samaritan College of Nursing & Health Science has revised how data will be obtained for the schedule of expenditures of federal awards. Additionally, the G5 report will be provided to National Grant Accounting with the SEFA. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Completion: February 2024

View Audit 301158

Finding 390260 (2023-103)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C2...

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C210057 and P031C210077, October 1, 2021 through September 30, 2026 P031S220015 and P031S220179, October 1, 2022 through September 30, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Reporting and special tests and provisions Questioned costs: Unknown Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Diana Aguirre-Rosales, Fiscal Director, Maricopa Community Colleges Foundation Anticipated completion date: December 31, 2024 The District is aware of the importance of ensuring that reports submitted are reviewed for accuracy prior to submission and implemented new processes for report review and submission in November 2023. On February 7, 2024, after multiple requests, the U.S. Department of Education (ED) provided the District with access to ED’s reporting system, which will allow the District to timely submit reports. The District will coordinate with the Maricopa Community Colleges Foundation to ensure that the endowment contracts include all necessary federal regulation information and that the investment and disbursement of funds are in accordance with federal regulations.

View Audit 301142 Questioned Costs: $1

Finding 390255 (2023-101)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Student Financial Aid Special Tests & Provisions § 200.303

Cluster Name: Student Financial Assistance Cluster Assistance Listing number and name: 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study Program 84.038 Federal Perkins Loan Program-Federal Capital Contributions 84.063 Federal Pell Grant Program 84.268 Fed...

Cluster Name: Student Financial Assistance Cluster Assistance Listing number and name: 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study Program 84.038 Federal Perkins Loan Program-Federal Capital Contributions 84.063 Federal Pell Grant Program 84.268 Federal Direct Student Loans Award Year: July 1, 2021 through June 30, 2022 Federal Agency: U.S. Department of Education Compliance Requirements: Special tests and provisions Questioned Costs: Unknown Name of Contact Persons: Joshua Lindenberg, District Director of Financial Aid Anticipated Completion Date: December 31, 2024 The Maricopa County Community College District understands the importance of reporting accurate student enrollment statuses and all student enrollment status changes to the National Student Loan Database (NSLDS) for the Pell and Direct Loan programs. System improvements were completed in June 2023 to reduce and prevent enrollment reporting errors. The District will continue to enhance internal controls by expanding procedures to proactively monitor, detect, and correct unresolved enrollment reporting errors and will conduct semi-annual quality assurance reviews of student accounts to ensure enrollment data is reported appropriately to the NSLDS. The district will assess and enhance the existing enrollment reporting transmission schedule, documenting and disseminating a final copy to staff to ensure optimal efficiencies and reduce enrollment reporting errors caused by the timing of data transmission and error processing.

View Audit 301142 Questioned Costs: $1

Finding 390252 (2023-002)

Significant Deficiency 2023

Kvc Health Systems, Inc.

KS

Cash Management Reporting Internal Control / Segregation of Duties

KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and ...

KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and work with their external advisors to ensure future portal submissions are compliant with said guidance. Going forward, the Organization will continue to improve its internal controls related to lost revenue calculations and reporting and work with their external advisors to ensure future portal submissions, if any, are compliant with said guidance. The under-reporting of lost revenues had no impact on the Organization’s ability to cover the total Provider Relief Fund payments received. This review will be performed by June 30, 2024. Responsible Official: Sherri Lohe Chief Financial Officer

View Audit 301134

Finding 390235 (2023-002)

Material Weakness 2023

National University

CA

Student Financial Aid Material Weakness Reporting

Finding 2023-002 - Special Tests and Provisions – Enrollment Reporting: Material Weakness in Internal Control Management agrees with this finding. The institution proposes a multifaceted approach aimed at resolving the root causes of the inaccuracies and preventing their recurrence. National Univer...

Finding 2023-002 - Special Tests and Provisions – Enrollment Reporting: Material Weakness in Internal Control Management agrees with this finding. The institution proposes a multifaceted approach aimed at resolving the root causes of the inaccuracies and preventing their recurrence. National University has implemented regular reviews of its enrollment reporting. During this process, errors in reporting are identified and corrected. However, the timing of the review has not allowed enough time to process corrections within compliance. To allow for appropriate adjustments and corrections to be implemented after testing but before the enrollment reporting deadline, National University will shift the timing of its enrollment reporting review from 60 to 30 days. Though NU is currently testing enrollment reporting and adjusting queries in an ongoing effort to improve accuracy, some of those adjustments inadvertently caused students to not appear in our queries. This impact on reporting occurred in edge cases not taken into account in the queries. To ensure this does not happen in the future, NU will implement a testing regime for these queries. This testing will be conducted at regular intervals to verify the effectiveness and accuracy of the queries in identifying students who have ceased attendance as required. Through these concerted efforts, NU hopes to demonstrate its full commitment to addressing the audit findings. We know that these efforts will take time to fully take effect and be reflected in future audits. Contact Person Responsible for Corrective Action: Brandy Baker, Director of Quality Assurance and Sarah Massey, AVP Operations, Student Support and Registrar Anticipated Completion Date: June 2024

View Audit 301132

Finding 390234 (2023-001)

Material Weakness 2023

National University

CA

Internal Control / Segregation of Duties Special Tests & Provisions Student Financial Aid

Management’s Corrective Action Plan National University acknowledges the findings and the recommendations regarding improving procedures. Finding 2023-001 - Special Tests and Provisions – Return of Title IV: Material Weakness in Internal Control National University agrees with this finding. As we c...

Management’s Corrective Action Plan National University acknowledges the findings and the recommendations regarding improving procedures. Finding 2023-001 - Special Tests and Provisions – Return of Title IV: Material Weakness in Internal Control National University agrees with this finding. As we continue to refine our R2T4 processes, we’ve had two key challenges we are addressing: Timeliness of R2T4 calculations: In FY22, NU identified an issue with how it was identifying unofficial withdrawals at the institution. To assist in rectifying the issue, we implemented a 35-day attendance policy that resulted in a significant amount of students being attritted from the University. We were working with a third-party firm to help us complete all the R2T4 calculations, which proved challenging; between our internal staffing and external support, we did not have the ability to do all of the calculations timely. As we’ve analyzed the needed manpower, we’ve expanded our Processing and Quality Assurance teams. The establishment of two additional teams within the Processing team in 2024 underscores our commitment to ensuring the timely completion of necessary calculations. Simultaneously, the increased Quality Assurance team is poised to support the enhanced internal controls, conducting weekly reviews of R2T4 calculations to verify their accuracy and timeliness. Missing students for R2T4 calculations who were withdrawn: We have established precise and accurate criteria for the development and execution of report queries. This initiative aims to ensure the comprehensive identification of students who discontinue attendance before the end of a payment period, thereby mitigating the risk of oversight. To bolster the reliability of these refined processes, NU is committed to implementing regular testing of the attendance queries. By conducting these tests at established intervals, the institution seeks to verify that the queries consistently identify the correct cohort of students. This approach serves as a crucial mechanism to maintain the accuracy of our withdrawal determination processes and underscores our dedication to continuous improvement. Through these concerted efforts, NU hopes to demonstrate its full commitment to addressing the audit findings. We know that these efforts will take time to fully take effect and be reflected in future audits. Contact Person Responsible for Corrective Action: Brandy Baker, Director of Quality Assurance Angela De Angelini, AVP Processing and Fiscal Operations Anticipated Completion Date: June 2024

View Audit 301132

Finding 390228 (2023-001)

Significant Deficiency 2023

Rider University

NJ

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Federal Pell Grant Program, Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268. Recommendation: We recommend the University review procedures around sending the correct information to the NSLDS. In addition, we recommend the University develop a process to help better oversee the ...

Federal Pell Grant Program, Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268. Recommendation: We recommend the University review procedures around sending the correct information to the NSLDS. In addition, we recommend the University develop a process to help better oversee the submissions completed by the third-party servicer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Registrar's Office can confirm the National Student Clearing House (NSC) enrollment history for all two students is accurate. It appears that there have been challenges with the National Student Loan Data System (NSLDS) receiving current data from NSC in a timely manner. We take action to ensure that we will work with Financial Aid and crossreference the Registrar's monthly submission report and/or weekly Withdrawal Report with an NSLDS' report provided by Financial Aid to address any discrepancies. We will also work with the NSC audit team to ensure if there are any other processes, that we can implement on our end to better oversee the submission with our third-party servicer (NSC). Name(s) of the contact person(s) responsible for corrective action: Justina Nicita, Assistant Registrar, and Miranda Cole, Director of Financial Aid. Planned completion date for a corrective action plan: 3/19/2024.

View Audit 301124

Finding 390227 (2023-003)

Significant Deficiency 2023

Do Good Multnomah

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that invoices can be prepared by someone other than the approver. In the immediate interim, invoices will be reviewed and signed by the CEO before submission by th...

The finance team has been expanded and with the guidance of a nonprofit finance consultant additional roles are set to be established so that invoices can be prepared by someone other than the approver. In the immediate interim, invoices will be reviewed and signed by the CEO before submission by the CFO.

View Audit 301123

Finding 390226 (2023-002)

Significant Deficiency 2023

Do Good Multnomah

OR

Allowable Costs / Cost Principles Cash Management Reporting

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices ...

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices of recording and maintaining records. We have since also consolidated our supply chain so that spenders are able to procure most supplies through one vendor, which will have reporting and tracking capabilities. We will also be making significant changes to how mileage reimbursement is documented and approved.

View Audit 301123

Finding 390216 (2023-003)

Significant Deficiency 2023

Enlace Chicago

IL

Reporting Significant Deficiency

Reporting Recommendation: We recommend that management follow established policies and procedures for timely preparation of reports under program requirements financial reports. Documented timing of preparation and approval should be maintained and documented. Views of Responsible Officials: There ...

Reporting Recommendation: We recommend that management follow established policies and procedures for timely preparation of reports under program requirements financial reports. Documented timing of preparation and approval should be maintained and documented. Views of Responsible Officials: There is no disagreement with this finding. Action taken in response to finding: Enlace Chicago is committed to timely completion of report submissions. Enlace Chicago has continued to review and approve reports prior to submission as required by the state agency. We will continue to put forth best efforts to take a step further and document preparation and review on the report form to satisfy the internal process requirement. Name of the contact person responsible for corrective action: Laura Velazquez, Director of Finance Planned completion date for corrective action plan: June 30, 2024.

View Audit 301111

Finding 390212 (2023-002)

Significant Deficiency 2023

California State University

CA

Reporting

The University will review and enhance its procedures and internal controls to ensure reporting requirements related to the HEERF grants are met and information is reported timely and accurately.

View Audit 301108

Finding 390208 (2023-001)

Significant Deficiency 2023

California State University

CA

Reporting

The University will further review and refine the policies and procedures to strengthen internal controls and to ensure the timely and accurate reporting to NSLDS.

View Audit 301108

Finding 390200 (2023-002)

None 2023

St. Lukes Health Network, Inc. and Controlled Entities

PA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

2023-002 – Reporting to the Common Origination and Disbursement (COD) System Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell...

2023-002 – Reporting to the Common Origination and Disbursement (COD) System Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network agrees with the finding, and will make the following enhancements to the process: A reconciliation between the amounts of St. Luke’s School of Nursing disbursements compared to COD disbursement records will be completed monthly starting Q4 2024 by downloading the SAS file from COD. Starting FY 2024, these reconciliations will be completed monthly. After Originating a PELL Grant or a Direct Loan, the Financial Aid Office will check COD to ensure that the Origination came back with an “Accepted” value before any disbursement can be made. The student will be notified of the error and Direct Loan proceeds will be refunded to the Department of Education. This will ensure the student was properly reported and sent a direct loan disbursement notification as required to notify the student of the date and amount of disbursement, the right to cancel and procedures to cancel. The Network is implementing this process beginning in Q4 of FY2024. All disbursement records for PELL Grant and Direct Loan payments will be sent to COD on the disbursement date and no later than 15 days of the disbursement occurring. Starting Q4 of FY 2024, all PELL Grant and Direct Loan payments will be checked to ensure that they are sent to COD within this acceptable date range. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.

View Audit 301103

Finding 390197 (2023-004)

None 2023

College Dreams, INC

OR

Reporting Significant Deficiency

Finding # 2023-004: Significant deficiency over preparation of schedule of expenditures of federal awards (SEFA). 93.677 Social Services Block Grant Department of Health and Human Services Finding: The Organization should have systems in place to prepare a complete and accurate SEFA. The Organizati...

Finding # 2023-004: Significant deficiency over preparation of schedule of expenditures of federal awards (SEFA). 93.677 Social Services Block Grant Department of Health and Human Services Finding: The Organization should have systems in place to prepare a complete and accurate SEFA. The Organization did not identify all federal awards and adjustments were made to the SEFA prepared by management. Recommendation: The Organization should implement additional procedures and controls to accurately capture all activity under federal awards in preparing the SEFA. Corrective Action: The Executive Director and Business Manager will use a grant and contract tracking log to ensure they are aware of all federal awards. Anticipated Completion Date: June 30, 2024

View Audit 301101

Finding 390196 (2023-003)

Significant Deficiency 2023

College Dreams, INC

OR

Reporting Significant Deficiency

Finding # 2023-003: Significant deficiency over reporting Immaterial noncompliance over reporting U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: An annual report is due within 90 days after end of the budget period. The annual performance report was not ...

Finding # 2023-003: Significant deficiency over reporting Immaterial noncompliance over reporting U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: An annual report is due within 90 days after end of the budget period. The annual performance report was not submitted timely. Recommendation: Management should keep track of due dates for reports to avoid late submission. Corrective Action: We will have the Executive Director, Business Manager and College+ Program Manager monitor and ensure reports are remitted timely. Anticipated Completion Date: June 30, 2024

View Audit 301101

Finding 390193 (2023-002)

None 2023

University of Rochester

NY

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Finding 2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing ...

Finding 2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2023-3/31/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges the Period 4 HRSA Reporting portal submission errors noted. The personnel and supply costs identified at St. James Hospital and Memorial Hospital of William F and Gertrude F Jones Inc. were all allowable and reported in Period 4, but were over- or under-stated in a particular quarter. Management acknowledges that St. James Hospital understated its lost revenue in Reporting Period 4. Management’s Corrective Action Plan: The University is unable to amend the Reporting Period 4 submissions. HRSA has only provided guidance to providers with respect to how to account for unallowable expenses identified in prior reporting periods. The portal submission expense items identified were all allowable expenses, but under- or over- reported in a particular quarter of the Period 4 Reporting. The lost revenue calculation for St. James Hospital was an error in reporting. Since there is no ability to amend the Period 4 reporting for either of these entities, the University will ensure that it documents these corrections in case of future inquiries from the HRSA. As noted above, the URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates in FY23 prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions. Contact person: Adam Anolik, URMC Senior Vice President and CFO, Adam_Anolik@URMC.Rochester.edu

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