Corrective Action Plans

Finding 517234 (2024-002)

Significant Deficiency 2024

Columbia Village

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management will review the policies and procedures currently in place relating to the retainment of journal entry support to ensure that all supporting documentation for entries made to the general ledger are kept validating the accuracy and purpose of journal entries.

View Audit 335234

Finding 517230 (2024-002)

Significant Deficiency 2024

Believe Schools, Inc. and Affiliate

IN

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

To Whom it may concern: This document serves as the response to the 2023-2024 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and addressed the comments that were included in the Uniform Guidance Major Program Findings. Please review the corrective action items in response to the...

To Whom it may concern: This document serves as the response to the 2023-2024 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and addressed the comments that were included in the Uniform Guidance Major Program Findings. Please review the corrective action items in response to the Audit Results and Comments: Education Stabilization Fund (ESSER Grant): The school was unable to provide construction contracts to allow auditors to verify that the required Davis-Bacon Act wording was included. ● The Principal, Angel Jackson-Anderson, and Dean of Operations, Kayla Marshall, will ensure that the proper contracts are received and filed for all services conducted under ESSER grants. Child Nutrition: The school did not maintain tally sheets to support the number of meals served. ● The Dean of Operations, Kayla Marshall, will ensure that the proper physical files (tally sheets) are maintained and filed monthly, both in digital and paper form. The principal will review these files monthly to ensure documents are not lost or misplaced. If you have any questions, concerns, or comments, please feel free to contact me the school principal, Angel Jackson-Anderson, Aanderson@believeschools.org. Many thanks, Angel Jackson-Anderson Principal, BELIEVE Circle City High School Kayla Marshall Dean of Operations, BELIEVE Circle City High School www.believeschools.org @believeschoolsindy admin@believeschools.org 317-296-1954 Angel Jackson-Anderson 11/07/2024 02:25PM UTC

View Audit 335212

Finding 517228 (2024-001)

Significant Deficiency 2024

Believe Schools, Inc. and Affiliate

IN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.334

To Whom it may concern: This document serves as the response to the 2023-2024 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and addressed the comments that were included in the Uniform Guidance Major Program Findings. Please review the corrective action items in response to the...

To Whom it may concern: This document serves as the response to the 2023-2024 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and addressed the comments that were included in the Uniform Guidance Major Program Findings. Please review the corrective action items in response to the Audit Results and Comments: Education Stabilization Fund (ESSER Grant): The school was unable to provide construction contracts to allow auditors to verify that the required Davis-Bacon Act wording was included. ● The Principal, Angel Jackson-Anderson, and Dean of Operations, Kayla Marshall, will ensure that the proper contracts are received and filed for all services conducted under ESSER grants. Child Nutrition: The school did not maintain tally sheets to support the number of meals served. ● The Dean of Operations, Kayla Marshall, will ensure that the proper physical files (tally sheets) are maintained and filed monthly, both in digital and paper form. The principal will review these files monthly to ensure documents are not lost or misplaced. If you have any questions, concerns, or comments, please feel free to contact me the school principal, Angel Jackson-Anderson, Aanderson@believeschools.org. Many thanks, Angel Jackson-Anderson Principal, BELIEVE Circle City High School Kayla Marshall Dean of Operations, BELIEVE Circle City High School www.believeschools.org @believeschoolsindy admin@believeschools.org 317-296-1954 Angel Jackson-Anderson 11/07/2024 02:25PM UTC

View Audit 335212

Finding 517219 (2024-001)

Significant Deficiency 2024

Hood River County School District

OR

Subrecipient Monitoring Significant Deficiency

FS‐2024‐008 Significant Deficiency Findings Summary: During our testing of the ESSER Wage Rate Requirements, we noted a significant deficiency. The District did not retain documentation in full for certified payroll reports from contracts for labor performed. We recommend that the District thoroughl...

FS‐2024‐008 Significant Deficiency Findings Summary: During our testing of the ESSER Wage Rate Requirements, we noted a significant deficiency. The District did not retain documentation in full for certified payroll reports from contracts for labor performed. We recommend that the District thoroughly documents and retains all appropriate documentation. Corrective Action Plan: the District has begun to request and collect certified payroll reports on all contractors as required by procurement policies. A system for tracking of certified payroll reports through contract completion will be implemented. Anticipated Completion Date: June 30, 2025

View Audit 335178

Finding 517198 (2024-002)

Significant Deficiency 2024

Big Sky Economic Development Corporation

MT

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Noncompliance with Davis-Bacon Wage Requirements Description of the Finding: BSEDC does not have internal controls in place to verify compliance with prevailing wage rates in the event that such loans are disbursed. Planned Corrective Actions: BSEDC’s Director of Business Finance/Program Finance Dir...

Noncompliance with Davis-Bacon Wage Requirements Description of the Finding: BSEDC does not have internal controls in place to verify compliance with prevailing wage rates in the event that such loans are disbursed. Planned Corrective Actions: BSEDC’s Director of Business Finance/Program Finance Director has amended the organization’s EDA-RLF Plan, including details on the Davis-Bacon requirements for any loan funding construction or renovations of more than $2,000. It will be the responsibility of Big Sky Finance to notify the borrower as soon as possible regarding the Davis-Bacon requirements for wages paid. The borrower will in turn notify their contractor of the requirement. Big Sky Finance will require evidence from the general contractor of the prevailing wages being paid prior to loan funds being disbursed. Timeline for Completion: The Davis-Bacon requirement for funds disbursed through BSEDC’s Federal EDARLF loan fund will be immediately implemented for all EDA-RLF loans funded going forward. BSEDC’s EDARLF Plan will be amended and approved by its Board of Directors within a reasonable amount of time. A draft of this change is in place. However, as a matter of practice, Davis-Bacon requirements will be adhered to from this date forward. Responsible Person or Party: BSEDC’s Director of Business Finance/Program Finance Director, will be responsible for making the changes to the plan, presenting to the Board and adhering to the plan going forward.

View Audit 335172

Finding 517197 (2024-001)

Significant Deficiency 2024

Big Sky Economic Development Corporation

MT

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Late Submission of Form ED-209 Description of the Finding: Big Sky Economic Development Corporation, Inc. (BSEDC) did not submit Form ED-209 within the required timeframe. The initial submission occurred on September 25, 2024, which was after the 30-day deadline. Errors were identified which require...

Late Submission of Form ED-209 Description of the Finding: Big Sky Economic Development Corporation, Inc. (BSEDC) did not submit Form ED-209 within the required timeframe. The initial submission occurred on September 25, 2024, which was after the 30-day deadline. Errors were identified which required correction and resubmission of the form. The final submission was completed on October 18, 2024, which was after the deadline. Planned Corrective Actions: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director will implement stricter internal controls and monitoring procedures to ensure all federal reports, including Form ED-209, are prepared accurately and submitted within the required deadlines. A review process will be added to the monitoring procedures to promptly address and correct any errors identified by federal agencies. Timeline for Completion: BSEDC will implement the internal controls and monitoring procedures with the next reporting that is due secondary review process in October 2024 with the completion and submission of the FY24 annual report to Federal EDA. Responsible Person or Party: BSEDC’s Senior Director of Finance is responsible for implementing the corrective action. Responsible Person or Party: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director are both responsible for ensuring that the secondary review is complete before submitting reporting to Federal EDA.

View Audit 335172

Finding 517180 (2024-002)

Significant Deficiency 2024

Union College

NE

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the enrollment effective date reported to NSLDS on the cam...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the enrollment effective date reported to NSLDS on the campus and program level is aligning with the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process Union Adventist University follows to ensure that enrollment effective dates as reported to NSLDS are submitted and coordinated through the Records Office. Records submits the list of enrollment effective dates to the National Student Clearinghouse. The Records office will be monitoring for error reports from National Student Clearinghouse that might affect the change of enrollment effective dates. The Records submits monthly reports to the National Student Clearinghouse for any changes that occur during the month. Name(s) of the contact person(s) responsible for corrective action: Tricia Harris, Director of Student Financial Services Planned completion date for corrective action plan: The goal date for this project to be completed is prior to the FY25 audit.

View Audit 335132

Finding 517132 (2024-003)

Significant Deficiency 2024

Brevard Housing Authority

NC

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

Finding 2024-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Assistance Listing Numbers: 14.850 Noncompliance – N. Special Tests and Provisions – Depository Agreements Non Compliance Material to the Financial Sta...

Finding 2024-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Assistance Listing Numbers: 14.850 Noncompliance – N. Special Tests and Provisions – Depository Agreements Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: PHAs are required to enter into depository agreements with their financial institution using the HUD-51999 (OMB No. 2577-0075) or a form required by HUD in the ACC. The agreements serve as safe guards for Federal funds and provide third-party rights to HUD (Section 9 of the ACC). Condition: Based on inspection of files and discussions with management, it was determined that depository agreements were not on file during the time of audit. Context: The Authority did not have depository agreements with their financial institutions on file during the time of audit. We were unable to verify the existence of depository agreements and unable to determine if the Authority met the terms of the agreements. Cause: There is a significant deficiency in internal controls over compliance for the special tests and provision type of compliance as management did not obtain the required depository agreements. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls for their partnered management company that assures the program is in compliance. Effect: The Public and Indian Housing Program is in non-compliance with the special tests and provisions type of compliance related to depository agreements. Recommendation: We recommend the Authority design and implement internal control procedures related to their partnered management companies that will assure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: We agree with the Auditors' findings. The identified finding occurred under a prior administration at the Authority. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Janie Holland, Finance Director, will be responsible to implement this corrective action by March 31, 2025.

View Audit 335003

Finding 517115 (2024-001)

Significant Deficiency 2024

Tallatoona Community Action Partnership, Inc.

GA

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Corrective Action Plan for Current Year Findings 2024-001 - Internal Control over Eligibility Corrective Action Plan: Community Services Director provided training on July 9th to cover monitoring results from the state. Training and a review was provided for income guidelines for certification of...

Corrective Action Plan for Current Year Findings 2024-001 - Internal Control over Eligibility Corrective Action Plan: Community Services Director provided training on July 9th to cover monitoring results from the state. Training and a review was provided for income guidelines for certification of applications and data entry processes, including timeliness of processing applications. Person(s) Responsible: Lucus Garcia-Myrick, Community Services Director Timing for Implementation: Provided Training in July 2024 Tallatoona Community Action, Fiscal Director Tracy Brown Tallatoona Community Action, Executive Director R. Scott Gray

View Audit 334990

Finding 516968 (2024-002)

Significant Deficiency 2024

South Carolina Primary Health Care Association

SC

Reporting Significant Deficiency

FINDINGS— FEDERAL AWARD PROGRAMS AUDIT Department of Health and Human Services 2024-002 Department of Health and Human Services – Assistance Listing No. 93.129 Recommendation: CLA recommends that a process is put in place to ensure the Federal Financial Reporting (FFR) deadline is met in future yea...

FINDINGS— FEDERAL AWARD PROGRAMS AUDIT Department of Health and Human Services 2024-002 Department of Health and Human Services – Assistance Listing No. 93.129 Recommendation: CLA recommends that a process is put in place to ensure the Federal Financial Reporting (FFR) deadline is met in future years. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program managers will verify and validate that the FFR is submitted. Completed FFR reports are sent to the program managers, verifying submission. A secondary staff member has now been given access to submit reports as a backup. Name of the contact person responsible for corrective action: Lisa Allen, CFO Planned completion date for corrective action plan: December 31, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Lisa Allen, CFO at 803-788-2778.

View Audit 334890

Finding 516963 (2024-001)

Significant Deficiency 2024

St. Clair County Housing Authority

IL

Questioned Costs HUD Housing Programs Eligibility

Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Significant Deficiency Housing Choice Voucher Program CFDA #14.871 & #14.EHV Corrective Action Plan: 1) SCCHA will be structured into two separate functions: eligibility and v...

Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Significant Deficiency Housing Choice Voucher Program CFDA #14.871 & #14.EHV Corrective Action Plan: 1) SCCHA will be structured into two separate functions: eligibility and verifications and rent calculations. New staff will concentrate on completing verification tasks, whereas experienced team members will manage the rent calculation processes. 2) SCCHA will enhance its monitoring and evaluation of HCVP files to boost accuracy and ensure adherence to regulatory and statutory standards concerning income projections and tenant rent calculations. The Compliance Officer will conduct one-on-one meetings to discuss the audit findings and address all identified discrepancies. Both an employee and the Compliance Officer will sign off on the review. 3) SCCHA will have scheduled monthly peer-to-peer audits with all Program Assistants to collectively review identified errors. This approach aims to facilitate continuous training and encourages active participation from all staff members, enhancing their understanding of the errors. 4) SCCHA has strengthened its disciplinary measures to Identify staff members who may lack the motivation or capability to meet the requirements of the role. If a staff member fails to maintain consistently successful audits of files for three consecutive months of 80% or above, a 90-day improvement plan will be initiated. Anticipated Completion Date: June 30, 2025 1) On-going. 2) On-going. 3) On-going. 4) On-going. Persons Responsible: Vera Jones, Executive Director Pam Jackson, Programs Director Suellen Riley-Keen, Program Integrity & Compliance Coordinator

View Audit 334861 Questioned Costs: $1

Finding 516926 (2024-001)

Significant Deficiency 2024

Mt. San Antonio Community College District

CA

Student Financial Aid Reporting Significant Deficiency

Federal Awards Findings And Recommendations 2024-001 Special Tests and Provisions - Enrollment Reporting View of Responsible Officials and Corrective Action Plan The Financial Aid and Admissions and Records departments in collaboration with the district, contracted with an outside consultant to he...

Federal Awards Findings And Recommendations 2024-001 Special Tests and Provisions - Enrollment Reporting View of Responsible Officials and Corrective Action Plan The Financial Aid and Admissions and Records departments in collaboration with the district, contracted with an outside consultant to help identify why the enrollment reporting process was not accurately reporting students' enrollment levels. It was identified that a system setting was not set to capture chnage sof enrollment levels within the specific terms. Based on the consultant recommendation, the district agreed to update system settings to accurately report student enrollment level changes throughout the term. These adjustments to the system settings will allow for the accurate and timely reporting of information to the National Student Loan Database System (NSLDS). This ongoing change to system settings is in place beginning with the Fall 2024 term. Additionally, the district has implemented internal controls to include: Developed additional training and Information Technology support structures to maintain data integrity associated with the National Student Clearinghouse (NSC) data submission, Developed pre data submission audit report to check for accuracy prior to the upload of required data to the NSC, and Created an internal work group consisting of financial aid and admissions and records professionals to review information associated with NSC reports prior to the scheduled submission of requested information. Implementation Date September 2024

View Audit 334838

Finding 516912 (2024-001)

Significant Deficiency 2024

West Palm Beach Housing Authority

FL

Questioned Costs HUD Housing Programs Eligibility

Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend management should designate one person to ensure that income is correctly calculated, and housing specialists have adequate training on income calculations in accordance with HUD and the Authority's adm...

Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend management should designate one person to ensure that income is correctly calculated, and housing specialists have adequate training on income calculations in accordance with HUD and the Authority's administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The WPBHA plans on providing all HCV Specialist with in depth refresher Rent Calculation training. Name(s) of the contact person(s) responsible for corrective action: Teresa Gonzalez & Darrell McIver Planned completion date for corrective action plan: March 2025

View Audit 334817 Questioned Costs: $1

Finding 516870 (2024-001)

Significant Deficiency 2024

American Councils for International Education: Actr/accels, Inc.

DC

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

National Security Language & Student Exchange - Assistance Listing No. 19.415 & 19.009 Recommendation: We recommend the Organization to design controls to ensure that there is an internal control designed to validate the timeline where the final FFATA reports were submitted/updated in the FSRS syst...

National Security Language & Student Exchange - Assistance Listing No. 19.415 & 19.009 Recommendation: We recommend the Organization to design controls to ensure that there is an internal control designed to validate the timeline where the final FFATA reports were submitted/updated in the FSRS system. If this timeline cannot be readily available, we also recommend contacting the FSRS portal to for further clarification on the FSRS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Finance Staff will take "screen shots" to validate the submission of FFATA reports when they are updated in the FSRS system. Name(s) of the contact person(s) responsible for corrective action: John Henderson, CFO Planned completion date for corrective action plan: 11-21-24 If the Department of State has questions regarding this plan, please call John Henderson, CFO, at 202-833-7522.

View Audit 334780

Finding 516748 (2024-003)

Significant Deficiency 2024

Sea Mar Community Health Center and Subsidiaries

WA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding Reference Number: 2024-003 Corrective Action: Sea Mar will create a list of all report deadlines and due dates and have multiple staff review and monitor the list to ensure deadlines are met. This process will mitigate the chances that reports are submitted late. Name of Contact Person: Dust...

Finding Reference Number: 2024-003 Corrective Action: Sea Mar will create a list of all report deadlines and due dates and have multiple staff review and monitor the list to ensure deadlines are met. This process will mitigate the chances that reports are submitted late. Name of Contact Person: Dustin Greer, CFO, DustinGreer@seamarchc.org Projected Completion Date: 3/31/2025

View Audit 334705

Finding 516743 (2024-001)

Significant Deficiency 2024

Sea Mar Community Health Center and Subsidiaries

WA

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

Finding Reference Number: 2024-001. Corrective Action: Sea Mar will follow up with additional training on the sliding fee scale for all employees who issue the discount to patients. This training will be done via Relias, which is Sea Mar's web-based training platform. A score of 100% will be require...

Finding Reference Number: 2024-001. Corrective Action: Sea Mar will follow up with additional training on the sliding fee scale for all employees who issue the discount to patients. This training will be done via Relias, which is Sea Mar's web-based training platform. A score of 100% will be required to pass. Employees who do not score 100% will be retrained and will retake the test. Sea Mar has set a goal to achieve accuracy percentage of 95% and achieved its goal with 97% pass rate, but still had a finding on the audit because Sea Mar did not reach 100%. Sea Mar conducts monthly audits to monitor accuracy. Sea Mar will continue to use a process that will require supervisors to review and sign off on employee's income verifications to ensure they are accurate. Supervisors will be expected to ensure this process is being conducted accurately at their sites and to retrain staff who are not accurately verifying income. This review and sign off process will be verified during the quarterly audit. The quarterly audit will also identify sites and staff who need additional training. Name of Contact Person: Harshiem Ross, Senior Vice President of Operations, HarshiemRoss@seamarchc.org Projected Completion Date: 3/31/2025

View Audit 334705

Finding 516733 (2024-001)

Significant Deficiency 2024

Springville Community and Rural Foundation, Inc. D/b/a Springville Community Academy

IN

Subrecipient Monitoring Procurement, Suspension & Debarment Significant Deficiency § 200.317 § 200.318 § 200.327

December 18, 2024 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Subject: Response to Uniform Guidance Audit Finding for FY23-24 Finding 2024-001 Procurement Significant Deficiency Federal Program: Charter Schools Program Assistance Listing Numbers: 84.282A Springville C...

December 18, 2024 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Subject: Response to Uniform Guidance Audit Finding for FY23-24 Finding 2024-001 Procurement Significant Deficiency Federal Program: Charter Schools Program Assistance Listing Numbers: 84.282A Springville Community Academy (SCA) plans to develop a written procurement policy that incorporates the Federal regulations and procurement standards identified in §200.317 through 200.327. I, Corbin Dietrich, will work with the Board of Directors of SCA and our consultants with Indiana Charters to develop the appropriate procurement policies and procedures. We plan to draft and approve the required policies at the board meeting in January 2025. Sincerely, Corbin Dietrich, Treasurer

View Audit 334699

Finding 516653 (2024-002)

Significant Deficiency 2024

Wood County Village Ii, Inc.

OH

HUD Housing Programs Significant Deficiency Special Tests & Provisions

Wood County Village II, Inc. HUD Project No. 042-HD102 Audit Firm: GBQ Partners LLC Audit Period: 07/1/23-06/30/24 CAP Prepared by: Dustin Watkins, CEO A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations. 2. Finding 2024-002 U.S. Department of Housing and U...

Wood County Village II, Inc. HUD Project No. 042-HD102 Audit Firm: GBQ Partners LLC Audit Period: 07/1/23-06/30/24 CAP Prepared by: Dustin Watkins, CEO A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations. 2. Finding 2024-002 U.S. Department of Housing and Urban Development Supportive Housing for Persons with Disabilities (Section 811) – CFDA 14.181; Grant period – Year ended June 30, 2024 a. Comments on the Finding and Each Recommendation. Statement of Condition: Security deposits assets collected from eligible families and the corresponding liability recorded, did not equal. Criteria: The HUD Handbook 4350.3 Occupancy Requirements of Subsidized Multifamily Housing Programs requires that the owner must place security deposits in a segregated, interest bearing-account, the balance of which must at all times be equal to the total amount collected from the eligible family plus any accrued interest. Cause: The Project experienced a fire in June 2024 that caused a lapse in assigned responsibility for the reconciliation and transfer of security deposits. Effect of Condition: This Project was not in compliance with the HUD Handbook. Recommendation: We recommend that the Project’s sponsor verify, on a monthly basis, the required security deposit asset and liability account equal. b. Action(s) Taken or Planned on the Finding 1. The Project’s sponsor is aware of the requirement to maintain security deposit records. 2. Due to the fire and displacement of tenants, the security deposit account has not been fully reconciled subsequent to year.

View Audit 334625

Finding 516608 (2024-001)

Significant Deficiency 2024

Prince George's Community College

MD

Subrecipient Monitoring Reporting Significant Deficiency

For the Year Ended June 30, 2024 All Programs Type of Finding: Significant Deficiency over Financial Reporting Repeat Finding: Yes Auditee Corrective Action Plan: The College experienced a transition in a key management position, Controller, at the end of fiscal year 2024. The Accounting Officer wi...

For the Year Ended June 30, 2024 All Programs Type of Finding: Significant Deficiency over Financial Reporting Repeat Finding: Yes Auditee Corrective Action Plan: The College experienced a transition in a key management position, Controller, at the end of fiscal year 2024. The Accounting Officer will revise and update the month-end and year-end closing activities to include detailed procedures, the roles of those responsible for the closing process, and strict monthly and yearly deadlines that support timely financial reporting. The Accounting Officer will monitor weekly the closing process to ensure that the month-end and year-end processes are competed on time. The Accounting Officer will meet with the Controller every two weeks to discuss the status of the month-end and year-end close. When the audit starts the Financial Services team will maintain regularly scheduled progress meetings to ensure the audit remains on track for timely submission and uphold the responsibility for ensuring that the audit is completed in a timely manner. A quarterly progress review will be conducted with the Vice President of Financial Services and Operations. Additionally, the Interim Controller will post, recruit, and hire the Senior Accountant and Payroll Officer positions for additional resources with appropriate accounting experience and knowledge. Completion Date: March 31, 2025 Dwight Washington Interim Controller

View Audit 334598

Finding 516578 (2024-001)

Significant Deficiency 2024

United Community and Family Services, Inc.

CT

Subrecipient Monitoring Eligibility Significant Deficiency

CORRECTIVE ACTION PLAN November 25, 2024 United States Department of Health and Human Services United Community & Family Services respectfully submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30...

CORRECTIVE ACTION PLAN November 25, 2024 United States Department of Health and Human Services United Community & Family Services respectfully submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2024 The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS Section III- Federal Award Findings and Questioned Costs Community Health Centers, COVID-19 Community Health Centers, Affordable Care Act (ACA) Grant for New and Expanded Services Under the Health Center Program, COVID-19 Affordable Care Act (ACA) Grant for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2024-001 – Special Tests Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Repeat Finding Not a repeat finding. Action Taken 1) Monthly internal audits of new and existing patient records being entered into our practice management system. This review will ensure appropriate completion is entered into the Sliding Fee Scale field. 2) Review of accounts when new income verification forms are received from the patients to ensure that reported income aligns with the practice management system. In addition, we will perform audits of no more than 15 active Sliding Fee Scale patients for proper Sliding Fee percentage and calculation. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please contact Frank Meaney, CFO at 860.822.4153. Sincerely yours, Frank Meaney Chief Financial Officer

View Audit 334517

Finding 516555 (2024-006)

Significant Deficiency 2024

United Way of the Battle Creek and Kalamazoo Region

MI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303

Auditor Description of Condition and Effect. During our testing we noted that there was not an independent review performed on journal entries related to their federal grant program. Without a review process, there is an increased risk of inaccurate financial reporting and potential noncompliance. A...

Auditor Description of Condition and Effect. During our testing we noted that there was not an independent review performed on journal entries related to their federal grant program. Without a review process, there is an increased risk of inaccurate financial reporting and potential noncompliance. Auditor Recommendation. We recommend that the Organization implement a formal review and approval process for all journal entries related to federal grant programs. Corrective Action. Management will implement an independent monthly review of all journal entries, including those related to the federal grant programs. The designated reviewer will be a senior accounting team member or equivalent who does not have the ability to create or approve journal entries in the general ledger system. The designated reviewer will compare the entries to ensure proper documentation, accurate amounts, correct coding, and compliance with the applicable federal grant regulations. Any discrepancies or issues identified during the review will be documented, and corrective actions will be taken immediately. The reviewer will sign off on the entries, confirming that all journal entries meet required standards. Responsible Person. Chris Sargent, President & Executive Officer Anticipated Completion Date. March 31, 2025

View Audit 334487

Finding 516545 (2024-004)

Significant Deficiency 2024

United Way of the Battle Creek and Kalamazoo Region

MI

Allowable Costs / Cost Principles Reporting Significant Deficiency

Auditor Description of Condition and Effect. During our testing we noted that there was not an independent review performed on quarterly grant expenditure reports before submission. This can cause an increased risk that reports filed could contain errors and not be detected and corrected on a timely...

Auditor Description of Condition and Effect. During our testing we noted that there was not an independent review performed on quarterly grant expenditure reports before submission. This can cause an increased risk that reports filed could contain errors and not be detected and corrected on a timely basis. Auditor Recommendation. We recommend that the Organization review its procedures for compiling financial data for external reporting purposes and develop an independent review process before report submission. Corrective Action. Management will implement a formal process requiring an independent review of all federal quarterly grant expenditure reports before submission. The designated reviewer will be a senior staff member or an individual independent of the preparation and approval process. This person will have sufficient expertise in grant management and financial reporting. The reviewer will carefully verify the accuracy of the data, confirm that all expenditures are correctly categorized, ensure compliance with grant terms, and validate calculations. Responsible Person. Chris Sargent, President & Executive Officer Anticipated Completion Date. January 31, 2025

View Audit 334487

Finding 516392 (2024-004)

Significant Deficiency 2024

McMurry University

TX

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Finding Summary: The information technology security risk assessment and safeguards, including financial aid applications, was not sufficiently documented and multi-factor authentication (MFA) was not implemented on all systems containing personally identifi...

Gramm-Leach-Bliley Act (GLBA) Compliance Finding Summary: The information technology security risk assessment and safeguards, including financial aid applications, was not sufficiently documented and multi-factor authentication (MFA) was not implemented on all systems containing personally identifiable information (PII). Responsible Individuals: Grant Greenwood, Interim Chief Operations Officer Corrective Action Plan: We agree with the auditors’ findings and recommendations. A change in contracted information technology service firms was initiated in February 2024 to be phased in by the existing contract termination date. New services include an on-site Chief Information Officer beginning August 2024. A pushout of MFA on all devices occurred during Fall 2024 semester. Other security enhancements are included. Anticipated Completion Date: December 31, 2024

View Audit 334328

Finding 516286 (2024-004)

Significant Deficiency 2024

Western Oregon University

OR

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

Finding: 2024-004 Federal Agency Name: U.S. Department of EducationAssistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: Awards must be coordinated among the various programs and with other federal and nonfede...

Finding: 2024-004 Federal Agency Name: U.S. Department of EducationAssistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: Awards must be coordinated among the various programs and with other federal and nonfederal aid (need and non-need-based aid) to ensure that total aid is not awarded in excess of the student’s financial need or cost of attendance (34 CFR 668.42, FWS, and FSEOG, 34 CFR 673.5 and 673.6; Direct Loan, 34 CFR 685.301). Financial need is defined as the student’s COA minus the student’s EFC (as computed by the central processor and included on the student’s SAR/ISIR). During the testing of compliance for Eligibility, it was noted students who worked as Resident Advisors for the University, did not have their Title IV aid adjusted for amounts they received via direct payments to cover the cost of their housing. As a result, the University compensated the students for the cost of their housing outside the normal processing and packaging of Title IV aid, resulting in $26,572 of Direct Loans being disbursed to student’s in excess of their financial need. Responsible Individuals: Kella Helyer, Director of Financial Aid Corrective Action Plan: The current year (2024-25) Resident Assistant benefits have been taken into consideration for all applicable students. Anticipated Completion Date: 9/10/2024

View Audit 334105 Questioned Costs: $1

Finding 516280 (2024-003)

Significant Deficiency 2024

Western Oregon University

OR

Reporting Special Tests & Provisions Student Financial Aid

Finding: 2024-003 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for ti...

Finding: 2024-003 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for timely and accurate reporting of a student’s enrollment status and changes in those enrollment statuses, whether they report directly or via a third‐party servicer. When an Institution is made aware of a change in a student’s enrollment status, the Institution has 60 days to update the change in enrollment status via NSLDS. The University pushed through the changes in enrollment status to the Clearinghouse timely and accurately based upon the student’s enrollment status; however, the change in enrollment status was not pushed through all the way to NSLDS resulting in inaccurate and untimely records within NSLDS. Responsible Individuals: Kella Helyer, Director of Financial Aid and Amy Clark, University Registrar Corrective Action Plan: There is documentation of the student’s enrollment status in the National Student Clearinghouse (NSC) for each month starting Fall term 2023. The enrollment reporting process functions such that each month, the National Student Loan Data System (NSLDS) sends a file to NSC for the students who have been awarded federal aid. NSC then sends a file back to NSLDS for the students on the list. This return file then updates the NSLDS enrollment reporting section in their system. NSC will not send enrollment for students if they are not on the NSLDS list. To do so would be a FERPA violation. For the student in question, NSLDS did not place their name on the list for reporting enrollment until June 2024. A second call to NSLDS has been placed requesting a response as to why this student was not reported. Anticipated Completion Date: 12/6/2024

View Audit 334105

Corrective Action Plans

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