Corrective Action Plans

Finding 514577 (2024-001)

Significant Deficiency 2024

University of Northwestern - St. Paul and Subsidiaries

MN

Significant Deficiency Equipment & Real Property Management Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit ...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  An Information Security Policy that addresses all policy gaps related to the GLBA audit findings will be presented to the President’s cabinet for approval by Dec. 2, 2024.  A migration of our Banner environment to Oracle Cloud Infrastructure will be completed by Nov. 6, 2024. This will include encrypting our database at rest, which is the last step in implementing best practices for encrypting our Banner data.  In addition to our annual security awareness training, we will complete an organizationwide phishing simulation by Dec. 31, 2024. Name(s) of the contact person(s) responsible for corrective action: Chad Miller Planned completion date for corrective action plan: December 31, 2024

View Audit 332923

Finding 514542 (2024-001)

Significant Deficiency 2024

West Hills Community College District

CA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan Based on the review and assessment of findings, Lemoore College will update its established policies and procedures to include a report to track all steps of the Return to Title IV process and the date each s...

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan Based on the review and assessment of findings, Lemoore College will update its established policies and procedures to include a report to track all steps of the Return to Title IV process and the date each step is completed for each student. The report will be reviewed periodically and compared with monthly reconciliation reports to ensure all steps have been completed within the required timeframes. This will ensure that each step of the return of Title IV process is completed within regulatory timelines.

View Audit 332845

Finding 514471 (2024-001)

Significant Deficiency 2024

University of Mary

ND

Reporting Significant Deficiency Internal Control / Segregation of Duties

Federal Agency Name: U.S. Department of Homeland Security Program Name and FALN # : # 97.047 2021 Award Year, Award Number: PDMV-PJ-08-ND-2018-003 Building Resilient Infrastructure and Communities. Finding Summary: There was no documented control in place to review quarterly reports prior to submiss...

Federal Agency Name: U.S. Department of Homeland Security Program Name and FALN # : # 97.047 2021 Award Year, Award Number: PDMV-PJ-08-ND-2018-003 Building Resilient Infrastructure and Communities. Finding Summary: There was no documented control in place to review quarterly reports prior to submission for the grant program. Responsible Individuals: Luke Seidling, Director of Physical Plant; Janel Sailer, Director of Budget Corrective Action Plan: Quarterly reports will be submitted electronically by the contracted vendor to the Director of Physical Plant for review. The Director of Physical Plant will review and electronically provide his approval. The report and record of approval will be sent to the Director of Budget for record retention. Anticipated Completion Date: This corrective action plan has been implemented as of November 1, 2024.

View Audit 332825

Finding 514465 (2024-002)

Significant Deficiency 2024

Rocky Mountain College

MT

Reporting Internal Control / Segregation of Duties Special Tests & Provisions

Finding 2024-002: In order to ensure proper compliance with reporting student enrollment statuses to the National Student Loan Data System, the CFO and Controller will familiarize themselves with federal reporting deadlines and inform other parties on campus who will need to report student enrollmen...

Finding 2024-002: In order to ensure proper compliance with reporting student enrollment statuses to the National Student Loan Data System, the CFO and Controller will familiarize themselves with federal reporting deadlines and inform other parties on campus who will need to report student enrollment changes on a timely basis. Furthermore, the CFO and Controller will review the sample of enrollment status changes the auditors reviewed for the fiscal year 2024 audit, and immediately develop procedures to strengthen internal controls surrounding the reporting of enrollment status changes.

View Audit 332801

Finding 514464 (2024-001)

Significant Deficiency 2024

Rocky Mountain College

MT

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

Finding 2024-001: In order to ensure proper compliance with the Federal Perkins Loan Program, the CFO and Controller will review the sample of 25 promissory notes the auditors reviewed for the fiscal year 2024 audit, and immediately develop procedures to strengthen internal controls surrounding the ...

Finding 2024-001: In order to ensure proper compliance with the Federal Perkins Loan Program, the CFO and Controller will review the sample of 25 promissory notes the auditors reviewed for the fiscal year 2024 audit, and immediately develop procedures to strengthen internal controls surrounding the retention of documents. Although the College was unable to locate the promissory note in question, the College did have a physical file which contained information about the student and the Perkins Loan which was issued over 30 years ago, including correspondence with debt collection agencies and a remaining balance as of June 20, 2024. Effective September 30, 2017, the Perkins Loan Program was terminated and no new loans have been issued since that time.

View Audit 332801

Finding 514462 (2024-001)

Significant Deficiency 2024

Village of Hempstead Housing Authority

NY

HUD Housing Programs Eligibility Significant Deficiency

Finding 2024-001 – Tenant Files Auditee’s Response and Planned Corrective Action HHA will take measures establish and utilize a check list as an internal control to be used by Housing Assistants to use during the recertification process to ensure all compliance requirements are met. The checklist w...

Finding 2024-001 – Tenant Files Auditee’s Response and Planned Corrective Action HHA will take measures establish and utilize a check list as an internal control to be used by Housing Assistants to use during the recertification process to ensure all compliance requirements are met. The checklist will be signed or initialed by the Housing Assistant, reviewed and signed by a member of management, and maintained in the tenants file. This checklist will serve as documentation that all compliance requirements are met. Planned Implementation Date of Corrective Action: December 5, 2023 Person Responsible for Corrective Action: Shereen Goodson, Executive Director Village of Hempstead Housing Authority Shereen Goodson, Executive Director

View Audit 332788

Finding 514431 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Frederick

MD

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

The Authority has hired a CPA firm to assist in overall procedures and processes, including compliance with federal awards.

View Audit 332764

Finding 514422 (2024-003)

Significant Deficiency 2024

Arlington Baptist University

CO

Student Financial Aid Allowable Costs / Cost Principles Significant Deficiency

Lack of Documentation of Exit Counseling Planned Corrective Action: Current SIS is set to trigger the Exit Counseling to all students that are coded anything other than E (Enrolled). The Registrar updates all student files with any enrollment changes triggering the email to go to the student. The FA...

Lack of Documentation of Exit Counseling Planned Corrective Action: Current SIS is set to trigger the Exit Counseling to all students that are coded anything other than E (Enrolled). The Registrar updates all student files with any enrollment changes triggering the email to go to the student. The FA Director will run a report in the middle of each term to pick up any students that may have been missed by the Registrar. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Anticipated Date of Completion: Fall 2024

View Audit 332741

Finding 514420 (2024-002)

Significant Deficiency 2024

Arlington Baptist University

CO

Questioned Costs Student Financial Aid Significant Deficiency

Return of Title IV (R2T4) Calculations Planned Corrective Action: Calander was set using prior year information it was not until notification in April 2024 from the DOE Audit Resolution Group that the error was made known to Financial Aid Director. Prior year R2T4 was handled by 3rd party vendor. T...

Return of Title IV (R2T4) Calculations Planned Corrective Action: Calander was set using prior year information it was not until notification in April 2024 from the DOE Audit Resolution Group that the error was made known to Financial Aid Director. Prior year R2T4 was handled by 3rd party vendor. The calendar for 2023-2024 was updated immediately and all calculations were processed and adjustments made. The ABU director has now taken NASFAA R2T4 Specialist training and is in charge of updating and maintaining the calendar. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Anticipated Date of Completion: Fall 2024

View Audit 332741 Questioned Costs: $1

Finding 514399 (2024-001)

Significant Deficiency 2024

Northeast New Jersey Legal Services CORP

NJ

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Internal Control over Compliance and Other Matters Recommendation: The organization should design and implement controls to ensure an adequate review process is in place to review compliance with LSC Regulation 45 C.R.F. Part 1611 Eligibility as it relates to obtaining and maintaining signed retain...

Internal Control over Compliance and Other Matters Recommendation: The organization should design and implement controls to ensure an adequate review process is in place to review compliance with LSC Regulation 45 C.R.F. Part 1611 Eligibility as it relates to obtaining and maintaining signed retainer agreements and eligibility forms for cases requiring such documentation. There is no disagreement with the audit finding. Action taken in response to finding: NNJLS created a Case File Checklist Form and implemented a procedure in which all supervising attorneys must complete the form weekly by reviewing cases to ensure that required signed retainer agreements and eligibility documentation are obtained by the client and uploaded to the case management system. The supervising attorney must report their findings of the review weekly to the Executive Director, obtain any necessary signatures and/or documents, and upload the Case File Checklist Form and documents to the case management system. The supervising attorneys receive a weekly-generated report of cases from the case management system. Name of the contact person responsible for corrective action: Leah Ashe, Executive Director Planned completion date for corrective action plan: As of September 30, 2024, this procedure became effective for all supervising attorneys and will remain in effect with no anticipated expiration.

View Audit 332699

Finding 514390 (2024-005)

Significant Deficiency 2024

Independent School District No. 361

MN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

Recommendation: We recommend that the District retain supporting documentation on file as required by federal guidelines for all transactions related to federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to f...

Recommendation: We recommend that the District retain supporting documentation on file as required by federal guidelines for all transactions related to federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement policies to ensure all documentation is kept. Name of the contact person responsible for corrective action: Phan Tu, Business Manager Planned completion date for corrective action plan: June 30, 2025

View Audit 332666

Finding 514386 (2024-001)

Significant Deficiency 2024

City of Virginia Beach, Virginia

VA

HUD Housing Programs Eligibility Significant Deficiency

Planned Corrective Action: DHNP will create a checklist for all staff, to ensure all documents are maintained in the file. DHNP has an effective Quality Control review process that was implemented February 2024. The audit findings were based on files completed in FY 23/24. All files go through the Q...

Planned Corrective Action: DHNP will create a checklist for all staff, to ensure all documents are maintained in the file. DHNP has an effective Quality Control review process that was implemented February 2024. The audit findings were based on files completed in FY 23/24. All files go through the QC process and if errors are found, they must be corrected before payments are approved to be released. Anticipated Completion Date: March 31, 2025 Responsible Contact Person: Ruth Hill, Director

View Audit 332661

Finding 514375 (2024-004)

Significant Deficiency 2024

Danville Area Community College

IL

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties § 200.303

Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College work to update the written security program to ensure compliance with all the standards. Explanation of disagreement with audit finding: There is no disagreeme...

Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College work to update the written security program to ensure compliance with all the standards. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: While the College's "written" information security program did not include the minimum requirements, all required activities were being performed. The College is in the process of updating its written information security program to achieve compliance with the Gramm-Leach-Bliley Act. Name of the contact person responsible for corrective action: Carl Lewis, Assistant Vice President and Chief Information Officer Planned completion date for corrective action plan: June 30, 2025

View Audit 332657

Finding 514374 (2024-003)

Significant Deficiency 2024

Danville Area Community College

IL

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

Student Financial Assistance Cluster – 84.063 and 84.268 Recommendation: We recommend the College reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disag...

Student Financial Assistance Cluster – 84.063 and 84.268 Recommendation: We recommend the College reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The College utilizes a third-party, National Student Clearinghouse (NSC) to report to NSLDS. The College will report to NSC earlier to provide additional time to review and verify that accurate data was transferred from NSC to NSLDS. Name of the contact person responsible for corrective action: Jonathan Jett, Director of Financial Aid Planned completion date for corrective action plan: June 30, 2025

View Audit 332657

Finding 514373 (2024-002)

Significant Deficiency 2024

Danville Area Community College

IL

Student Financial Aid Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College implement policies and procedures surrounding reviews of return of title IV calculations and direct loan reconciliations. Explanation of disagreement with audi...

Student Financial Assistance Cluster– Assistance Listing Number: 84.007, 84.033, 84.063, and 84.268 Recommendation: We recommend the College implement policies and procedures surrounding reviews of return of title IV calculations and direct loan reconciliations. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: The return of title IV calculations and the direct loan reconciliations are generated by Colleague and verified by a Financial Aid Staff member utilizing a different method for the calculation. Effective immediately the Financial Director will review the calculation and initial approval. Name of the contact person responsible for corrective action: Jonathan Jett, Director of Financial Aid Planned completion date for corrective action plan: Completed

View Audit 332657

Finding 514362 (2024-001)

Significant Deficiency 2024

Douglas County School District Re.1

CO

Procurement, Suspension & Debarment Subrecipient Monitoring School Nutrition Programs § 200.318 § 200.326

Child Nutrition Cluster - Assistance Listing Nos. 10.553, 10.555, 10.559 Recommendation: We recommend the District review their controls and procedures surrounding procurement to ensure their purchasing policy is followed. Explanation of disagreement with audit finding: There is no disagreement with...

Child Nutrition Cluster - Assistance Listing Nos. 10.553, 10.555, 10.559 Recommendation: We recommend the District review their controls and procedures surrounding procurement to ensure their purchasing policy is followed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will review the Sole Soure form on an annual basis to make sure the form has not expired. Name(s) of the contact person(s) responsible for corrective action: Debrah Jones, Director of Strategic Sourcing and Contract Management (SSCM) Planned completion date for corrective action plan: 12/31/2024

View Audit 332655

Finding 514319 (2024-002)

Significant Deficiency 2024

Alpha One

ME

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

2024-002 – 93.432 ACL Centers for Independent Living Significant Deficiency and Noncompliance: One expense charged to this major federal award program lacked readily available support and 2 expenses did not have documented approval. Questioned Costs: Expenses charged to major federal award program...

2024-002 – 93.432 ACL Centers for Independent Living Significant Deficiency and Noncompliance: One expense charged to this major federal award program lacked readily available support and 2 expenses did not have documented approval. Questioned Costs: Expenses charged to major federal award program for which there was not readily available support or approval of expenditures was not documented totaled $558. Recommendation: Procedures should be implemented requiring documentation be maintained to support every expense charged to federal programs including documentation of approval of expenditures. Responsible Person for Corrective Action: Thomas Newman, Executive Director Corrective Action to be Taken: Management agrees with the audit findings and has already taken immediate corrective action by re-training accounting staff on the importance of maintaining all supporting documentation and obtaining the necessary approvals before processing any cash disbursements. To further strengthen internal controls, management is exploring the implementation of a system upgrade that would automate the documentation and approval process for expenditures charged to federal award programs. The anticipated completion date for this corrective action is 11/30/2024.

View Audit 332596 Questioned Costs: $1

Finding 514265 (2024-007)

Significant Deficiency 2024

Alameda Health System, A Public Hospital Authority

CA

Subrecipient Monitoring Cash Management Reporting § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will ensure that the FEMA reimbursement requests have clear evidence of the individuals preparing and reviewing of the submission. Documentation will be maintained to evidence preparat...

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will ensure that the FEMA reimbursement requests have clear evidence of the individuals preparing and reviewing of the submission. Documentation will be maintained to evidence preparation and review process.

View Audit 332508

Finding 514264 (2024-006)

Significant Deficiency 2024

Alameda Health System, A Public Hospital Authority

CA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure that expenditures being charged to the program are specifically identified in the grant contract.

View Audit 332508

Finding 514262 (2024-004)

Significant Deficiency 2024

Alameda Health System, A Public Hospital Authority

CA

Allowable Costs / Cost Principles Period of Performance Cash Management § 200.403

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance period...

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance periods. Review of cost activity will occur in fiscal year 2025 to ensure policy is followed.

View Audit 332508

Finding 514260 (2024-002)

Significant Deficiency 2024

Alameda Health System, A Public Hospital Authority

CA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System finalized the standard work procedures titled, Internal Controls for Proper Verification, which include procedures to ensure reported timesheet hours agree to hours on the time study a...

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System finalized the standard work procedures titled, Internal Controls for Proper Verification, which include procedures to ensure reported timesheet hours agree to hours on the time study and costs incurred are appropriately charged based on the contracts’ performance periods. Staff is implementing policy in fiscal year 2025.

View Audit 332508

Finding 514236 (2024-001)

Significant Deficiency 2024

Boston Area Rape Crisis Center, Inc.

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Corrective Action Plan: (unaudited): We agree with the recommendation and have updated the accounting manual. It should also be noted that the Organization has never filed late and has only had this happen once in the history of the Organization which is concurrent with the change in the FAC website...

Corrective Action Plan: (unaudited): We agree with the recommendation and have updated the accounting manual. It should also be noted that the Organization has never filed late and has only had this happen once in the history of the Organization which is concurrent with the change in the FAC website update.

View Audit 332431

Finding 514214 (2024-002)

Significant Deficiency 2024

Sports Leadership and Management Academy of Nevada

NV

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2024-002 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be ...

Finding Number: 2024-002 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025

View Audit 332414

Finding 514203 (2024-003)

Significant Deficiency 2024

Doral Academy of Nevada

NV

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2024-003 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be ...

Finding Number: 2024-003 – Approval of Payroll Expense Transactions Corrective Action Plan: A process was put in place in January 2024 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2025

View Audit 332410

Finding 514194 (2024-002)

Significant Deficiency 2024

Austin Achieve Public Schools, Inc.

TX

Allowable Costs / Cost Principles Reporting School Nutrition Programs

AAPS has corrected for this finding at the beginning of FY25 by having offer letters issued by our HR Manager to all employees. Offer letters are securely stored in individual employees’ personnel folders.

View Audit 332402

Corrective Action Plans

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