Corrective Action Plans

Finding 4288 (2023-001)

None 2023

NY

HUD Housing Programs Cash Management Reporting

Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently i...

Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently in communication with HUD discussing options of a possible waiver for the required deposit or the possibility of making the deposit with promise of approval for immediate release

View Audit 6601

Finding 4285 (2023-002)

Material Weakness 2023

Town of Hingham, Massachusetts

MA

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

Hingham Public Schools has circulated training guides and templates to grant writers on the requirement to have time and effort reporting completed in a timely manner for staff assigned to specific grants. Grant accounting associates have also been provided with the training material to ensure that ...

Hingham Public Schools has circulated training guides and templates to grant writers on the requirement to have time and effort reporting completed in a timely manner for staff assigned to specific grants. Grant accounting associates have also been provided with the training material to ensure that there is an additional review of time and effort reports as part of the grant accounting, review and finalization process.

View Audit 6595 Questioned Costs: $1

Finding 4281 (2023-008)

Significant Deficiency 2023

City Colleges of Chicago

IL

Reporting Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Finding 2023-008 – Student Financial Assistance Cluster – Fraudulent Enrollment Condition City Colleges did not timely report information regarding potential fraudulent student enrollments to the Department of Education’s Office of Inspector General (OIG). City Colleges identified a total of 23 stu...

Finding 2023-008 – Student Financial Assistance Cluster – Fraudulent Enrollment Condition City Colleges did not timely report information regarding potential fraudulent student enrollments to the Department of Education’s Office of Inspector General (OIG). City Colleges identified a total of 23 students where the Enrollment and Admissions Departments discovered submission of fraudulent documents to verify residency. City Colleges performed a thorough investigation of student enrollment and verified that no aid was disbursed for these identified fraudulent enrollments Cause City Colleges experienced turnover in the Admissions Department and was training a new employee. The new employee did not have enough training or experience to identify fraudulent documents when the students enrolled with the college and registered for classes. City Colleges was not aware that this issue was required to be reported to the Department of Education. Corrective Action Taken or Planned: The College will review and monitor the Department of Education regulations. The Student Financial Aid will continue to train employees on the regulations and will timely report issues to the Department of Education. Contact Person: Tiffany Morrison, Associate Vice Chancellor – Financial Aid & Scholarship Anticipated Completion Date: In progress

View Audit 6574

Finding 4280 (2023-007)

Significant Deficiency 2023

City Colleges of Chicago

IL

Reporting Internal Control / Segregation of Duties § 200.303

Finding 2023-007 – COVID-19 Education Stabilization Fund: Higher Education Emergency Relief Fund Annual Reporting Condition City Colleges did not accurately report certain information required in the calendar year 2022 annual report. The following instances of noncompliance were identified: • HEER...

Finding 2023-007 – COVID-19 Education Stabilization Fund: Higher Education Emergency Relief Fund Annual Reporting Condition City Colleges did not accurately report certain information required in the calendar year 2022 annual report. The following instances of noncompliance were identified: • HEERF Institutional Portion: City Colleges submitted the annual report for Olive Harvey for the period of January 1, 2022 – December 31, 2022 which did not reconcile to the underlying expense detail as of the date of the report. The difference was $234,118 which was a result of a figure being double counted in the total. • HEERF Institutional Portion: City Colleges submitted the annual report for Malcolm X for the period of January 1, 2022 – December 31, 2022 which did not reconcile to the underlying expense detail as of the date of the report. The difference was $5,580,216 which was a result of a figure being double counted in the total. Cause City Colleges did not have effective internal controls in place to ensure reports were submitted accurately. Corrective Action Taken or Planned Finance will validate and review the OH and MX 2023 annual report for HEERF prior to submission in 2024. Financial Aid will submit the required HEERF Annual Reporting Correction for OH and MX. In addition, will submit the final required 2023 HEERF annual report. Contact Person: Tiffany Morrison, Associate Vice Chancellor, Financial Aid. Anticipated Completion Date: December 31, 2023

View Audit 6574

Finding 4272 (2023-005)

Significant Deficiency 2023

City Colleges of Chicago

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2023-005– Student Financial Assistance Cluster Internal Control over Compliance Condition City Colleges did not have sufficient documentation that internal controls were in place and operating effectively relative to the following areas: • Allowable Activities: For each of the seven campus...

Finding 2023-005– Student Financial Assistance Cluster Internal Control over Compliance Condition City Colleges did not have sufficient documentation that internal controls were in place and operating effectively relative to the following areas: • Allowable Activities: For each of the seven campuses, City Colleges did not have sufficient supporting evidence that review controls were performed over the transfer, carryforward, carryback, and administrative cost calculations in the Fiscal Operations Report and Application to Participate (FISAP) for award year July 1, 2021 through June 30, 2022 submitted during fiscal year 2023. • Reporting: For each of the seven campuses, City Colleges did not have sufficient supporting evidence that secondary review controls were performed over FISAP data for award year July 1, 2021 through June 30, 2022 submitted during fiscal year 2023. Cause City Colleges did not formally document the additional reviews and approvals over the department’s review of the FISAP. Corrective Action Taken or Planned Financial Aid will develop and document a review/approval process that will detail accurate reporting, secondary reviews, and review/approval of FISAP submissions and completions. Contact Person: Tiffany Morrison, Associate Vice Chancellor, Financial Aid Anticipated Completion Date: December 31, 2023

View Audit 6574

Finding 4268 (2023-003)

Significant Deficiency 2023

City Colleges of Chicago

IL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2023-003 – Common Origination and Disbursement (COD) Reporting Condition For ten out of forty students tested (25%), the College did not report certain disbursements of financial aid to COD within the require fifteen days from the date of disbursement. In all instances, the disbursements we...

Finding 2023-003 – Common Origination and Disbursement (COD) Reporting Condition For ten out of forty students tested (25%), the College did not report certain disbursements of financial aid to COD within the require fifteen days from the date of disbursement. In all instances, the disbursements were reported one day late. Cause The financial aid office inadvertently miscalculated the reporting date. Corrective Action Taken or Planned Financial Aid will add additional monitoring controls of COD files to ensure timely reporting. Contact Person: Tiffany Morrison, Associate Vice Chancellor, Financial Aid Anticipated Completion Date: December 31, 2023

View Audit 6574

Finding 4265 (2023-001)

Significant Deficiency 2023

City Colleges of Chicago

IL

Student Financial Aid Subrecipient Monitoring Reporting § 200.303

Finding 2023-001 – Enrollment Reporting Condition For four out of sixty students tested (7%) who withdrew from City Colleges, the students’ withdrawal date reported to the National Student Loan Data System (NSLDS) for campus level and program level did not match the institution’s records. Cause Th...

Finding 2023-001 – Enrollment Reporting Condition For four out of sixty students tested (7%) who withdrew from City Colleges, the students’ withdrawal date reported to the National Student Loan Data System (NSLDS) for campus level and program level did not match the institution’s records. Cause The financial aid office does not have an effective system in place to ensure all official student status changes are reported to the lender accurately. Corrective Action Taken or Planned City Colleges sends enrollment files of all students to the National Student Clearinghouse monthly, who then reports CCC enrollment data to NSLDS. City Colleges (Records, Financial Aid, Decision Support and the Office of Information Technology) continues to meet bi-weekly to review and update the enrollment reporting logic to ensure the dates for student enrollment actions align at the campus level and the program level. Contact Person: Laura Clark, Associate Vice Chancellor, Academic Systems and Tiffany Morrison, Associate Vice Chancellor, Financial Aid. Anticipated Completion Date: May 1, 2024

View Audit 6574

Finding 4218 (2023-001)

None 2023

New Mexico Educational Assistance Foundation

NM

Reporting

We acknoledge that these impacted accounts exceeded the allowable window for processing and in some cases resulting in penalties and accounts becoming uninsured. In the fourth quarter of 2022, we indentified an issue with the timing of claim processing. This issue impacted numerous claims. To addres...

We acknoledge that these impacted accounts exceeded the allowable window for processing and in some cases resulting in penalties and accounts becoming uninsured. In the fourth quarter of 2022, we indentified an issue with the timing of claim processing. This issue impacted numerous claims. To address the issue, we replaced the previous claims structure, reassigning claims processing to the Operations Department in approximately March 2023. Updated procedures have been created and additional staff has been training to support the process. The movement of claims processing to the operations department revmoves the single point of failure condition that led to this breakdown. The new team has been diligently working through the impacted accounts and has remedied most of the late filings. Currently, new claism are being processed within the required timelines. There are still some remaining accounts that are in the correction process, but every impacted account has been identified.

View Audit 6546

Finding 4216 (2023-002)

Significant Deficiency 2023

Poynette School District

WI

Reporting Internal Control / Segregation of Duties

Management Views - Management agrees with the finding and the recommendation. Corrective Action Planned - Management and the Board will continue to designate competent staff to oversee and review the financial reports and approve them before issuance. However, it is not feasible or cost effective to...

Management Views - Management agrees with the finding and the recommendation. Corrective Action Planned - Management and the Board will continue to designate competent staff to oversee and review the financial reports and approve them before issuance. However, it is not feasible or cost effective to add staff with the competence to prepare these reports.

View Audit 6543

Finding 4215 (2023-001)

Significant Deficiency 2023

Realife Cooperative of St. Peter

MN

Reporting Internal Control / Segregation of Duties

Housing and Urban Development Realife Cooperative of St. Peter respectfully submits the following corrective action plan for the year ended September 30, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: September 30, 2023 The finding from the Septe...

Housing and Urban Development Realife Cooperative of St. Peter respectfully submits the following corrective action plan for the year ended September 30, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: September 30, 2023 The finding from the September 30, 2023 schedule of findings and questioned costs and the summary schedule of prior audit findings is discussed below. The finding is numbered consistently with the number assigned in the schedules. Summary of audit results does not include findings and is not addressed. Finding 2023-001 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 6538

Finding 4214 (2023-001)

Significant Deficiency 2023

City of Norco

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

There is no disagreement with the audit finding. The City will make corrections on the next annual report as of March 31,2024 which should cover the period April 1 2023 through March 31, 2024. As of June 30, 2023, the City had fully expended the American Resue Plan Act (ARPA) funding. It is importan...

There is no disagreement with the audit finding. The City will make corrections on the next annual report as of March 31,2024 which should cover the period April 1 2023 through March 31, 2024. As of June 30, 2023, the City had fully expended the American Resue Plan Act (ARPA) funding. It is important to note that because the City's allocation of ARPA funds is less than $10 million, the Department of Treasury Regulations allows the City to use all its allocation as lost revenue replacement. This allows the City Council to appropriate ARPA funds for any legal government purpose except those that are prohibited. The City treated all its allocation as lost revenue replacement.

View Audit 6534

Finding 4212 (2023-003)

Significant Deficiency 2023

Merton Community School District

WI

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

Corrective Action Plan: The District will initiate the development of an equipment tracking system that adheres to federal requirements. Training sessions will be conducted for relevant staff to ensure proper understanding and compliance with the new tracking procedures.

View Audit 6526

Finding 4204 (2023-006)

Significant Deficiency 2023

YWCA Metropolitan Phoenix

AZ

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

Recommendation: Implement policies and procedures that ensure required reports are reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will updat...

Recommendation: Implement policies and procedures that ensure required reports are reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will update and implement policies and procedures that ensure required reports are reviewed and approved by a second, independent individual. Name(s) of the contact person(s) responsible for corrective action: Debbie Esparza Planned completion date for corrective action plan: January 31, 2024

View Audit 6513

Finding 4176 (2023-004)

Significant Deficiency 2023

Borger Junior College District

TX

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The College agrees that Enrollment Reporting should be submitted in a timely manner. The College is actively working with the new SIS to ensure the ability to be able to produce the reports.

View Audit 6498

Finding 4146 (2023-003)

Significant Deficiency 2023

University of Mount Olive, Inc.

NC

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Name of Responsible Individual: Terri Grice, University Registrar Corrective Action: The Registrar’s Office is continuously cross-training all team members so duties are cross-checked, shared by at least two team members, and completed in a timely manner. The reports used by this office will be rev...

Name of Responsible Individual: Terri Grice, University Registrar Corrective Action: The Registrar’s Office is continuously cross-training all team members so duties are cross-checked, shared by at least two team members, and completed in a timely manner. The reports used by this office will be reviewed on a frequent basis to ensure information is being reported as it was intended. The team will also meet with other departments on a frequent basis to ensure information is shared in a timely manner and continue to train on the regulations and policies between our institution, Clearinghouse, and NSLDS to ensure accurate reporting of information. Anticipated Completion Date: February 23, 2024

View Audit 6454

Finding 4145 (2023-001)

None 2023

University of Mount Olive, Inc.

NC

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

Name of Responsible Individual: Brian K. Blackburn, Director of Financial Aid Corrective Action: The University has implemented a weekly COD maintenance file update that will report any change activity to a student’s COD funds. This process is ensured to take place by ongoing calendar reminders as ...

Name of Responsible Individual: Brian K. Blackburn, Director of Financial Aid Corrective Action: The University has implemented a weekly COD maintenance file update that will report any change activity to a student’s COD funds. This process is ensured to take place by ongoing calendar reminders as well as progress checks between the Director and Assistant Director. Anticipated Completion Date: November 6, 2023

View Audit 6454

Finding 4133 (2023-004)

Material Weakness 2023

School District of Norwalk-Ontario-Wilton

WI

Cash Management Reporting School Nutrition Programs

Child Nutrition Reporting - Contact: Jeremy Mack, Business Agent. Completion date: June 30, 2024. The District administrator has reviewed the reporting requirements with the Child Nutrition staff and will review monthly claims for submission.

View Audit 6442

Finding 4069 (2023-001)

None 2023

Abilene Christian University

TX

Student Financial Aid Reporting Special Tests & Provisions

Responsible Individual: Eric Gumm Registrar and Director of the First-Year Program and Academic Development Center Abilene Christian University Finding 2023-001 concerning Enrollment Reporting Agency Name: U.S. Department of Education Program Name: Federal Pell Grant, Federal Direct Student Loans Oc...

Responsible Individual: Eric Gumm Registrar and Director of the First-Year Program and Academic Development Center Abilene Christian University Finding 2023-001 concerning Enrollment Reporting Agency Name: U.S. Department of Education Program Name: Federal Pell Grant, Federal Direct Student Loans October 13, 2023 Finding Summary: Enrollment Reporting (34 CFR 690.93(b)(2); 34 CFR 682.610; 34 CFR 685.309) Institutions are required to report enrollment information. The University’s processes did not ensure timely and accurate student status reporting to National Student Loan Data System (NSLDS). Out of the population of 1,079 students with student attendance changes required to be reported prior to July 19, 2022 or after February 28, 2023, a sample of 25 students were selected for testing. The University reported the incorrect Program Enrollment Effective Date for 10 students and did not timely report a status change for one student. Corrective Action Plan (CAP): After review, the University acknowledges and understands the findings associated with the reporting date of enrollment changes. ACU's official policy regarding recording the effective date of a status change is to designate the date reflected in the SFAREGS screen in Banner as the official date of determination. This is the date that will be reported to NSLDS for any student status changes. Anticipated Completion Date: Within the Fall semester, the University Registrar’s Office will implement sole use of the dates as shown in our Banner mainframe system’s SFAREGS screen for reporting enrollment statuses. This will afford the consistency of dates needed.

View Audit 6383

Finding 4065 (2023-004)

Significant Deficiency 2023

Pembroke Housing for the Elderly, Inc.

NH

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting

Plan: Job duties will be documented for each position and a policy will be implemented to ensure all time sheets detail the duties performed. Anticipated Completion: June 30, 2023 ...

Plan: Job duties will be documented for each position and a policy will be implemented to ensure all time sheets detail the duties performed. Anticipated Completion: June 30, 2023 Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6375

Finding 4052 (2023-005)

Significant Deficiency 2023

Newbury Elderly Housing, Inc.

NH

Allowable Costs / Cost Principles Reporting

Plan: Job duties will be documented for each position and a policy will be implemented to ensure all time sheets detail the duties performed. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6374

Finding 4042 (2023-002)

Significant Deficiency 2023

Municipality of Quebradillas

PR

Subrecipient Monitoring Reporting § 200.328

The Municipality established internal control to maintain schedule of the due date reports in order to avoid this situation.

View Audit 6364

Finding 4021 (2023-004)

None 2023

Drew Memorial Hospital, Inc. D/b/a Drew Memorial Health System

AR

Questioned Costs Allowable Costs / Cost Principles Reporting

Responsible Party: Melodie Colwell Finding 2023-004 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on th...

Responsible Party: Melodie Colwell Finding 2023-004 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management considers the expenditures reported to be in compliance with program regulations. Management agrees with the finding that additional supporting documentation should be retained. Going forward, for subsequent reporting periods related to the Provider Relief Fund and American Rescue Plan Rural Distribution management will implement controls to ensure all underlying support related to expenses is documented and retained. Estimated completion and implementation date for the above-mentioned corrective action plan is March 31, 2024.

View Audit 6331 Questioned Costs: $1

Finding 4020 (2023-003)

Material Weakness 2023

Drew Memorial Hospital, Inc. D/b/a Drew Memorial Health System

AR

Questioned Costs Allowable Costs / Cost Principles Reporting

Responsible Party: Melodie Colwell Finding 2023-003 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that were reimbursed through other funding sources and reported expenditures that did not have supporting documentation showing expenditures were ...

Responsible Party: Melodie Colwell Finding 2023-003 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that were reimbursed through other funding sources and reported expenditures that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management agrees with the finding that expenses should be reimbursed by only one source. Management believes that while certain expenses were reported that were reimbursed by other funding sources they have additional allowable expenditures that could have been reported. Going forward, for subsequent reporting periods related to the Provider Relief Fund and American Rescue Plan Rural Distribution management will allocate expenditures as required, and will ensure expenses are reimbursed in accordance with current guidance. Estimated completion and implementation date for the above-mentioned corrective action plan is March 31, 2024.

View Audit 6331 Questioned Costs: $1

Finding 4019 (2023-002)

Significant Deficiency 2023

Drew Memorial Hospital, Inc. D/b/a Drew Memorial Health System

AR

Reporting Internal Control / Segregation of Duties

Responsible Party: Melodie Coldwell Finding 2023-002 The Hospital submitted the provider relief fund report without proper review. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Manag...

Responsible Party: Melodie Coldwell Finding 2023-002 The Hospital submitted the provider relief fund report without proper review. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management will take action to implement controls around the provider relief fund report for proper completion and review. Estimated completion date for the above-mentioned corrective action is March 31, 2024.

View Audit 6331

Finding 4004 (2023-001)

Significant Deficiency 2023

Augustana University Association

SD

Student Financial Aid Reporting Significant Deficiency

Department of Education Augustana University respectfully submits the following corrective action plan for the year ended July 31, 2023. Audit period: August 01, 2022 – July 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consis...

Department of Education Augustana University respectfully submits the following corrective action plan for the year ended July 31, 2023. Audit period: August 01, 2022 – July 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no findings in the current year that require corrective action plan. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF EDUCATION 2023-001 Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.007, 84.0033, 84.063, 84.268, 84.379 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have implemented a secondary compliance check of student withdrawal dates. As the Registrar Assistant is notified of student withdrawals, the ‘Leave Date’ is entered into the Jenzabar/CX system. On a weekly basis, the Assistant Registrar will double check the withdrawal notice with the date in Jenzabar/CX. Performing this double check on a weekly basis should catch any incorrectly entered dates before they are transmitted to NSLDS. If an incorrectly entered date is found, the Assistant Registrar will notify the Director of Financial Aid, who will check NSLDS to further ensure the date has not been incorrectly included in enrollment reporting. Name(s) of the contact person(s) responsible for corrective action: Joni Krueger Planned completion date for corrective action plan: immediately / already implemented If the Department of Education has questions regarding this plan, please call Joni Krueger at 605.274.4121.

View Audit 6326

Corrective Action Plans

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