Corrective Action Plans

Finding 384914 (2023-031)

Significant Deficiency 2023

State of Vermont

VT

Eligibility Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

1. With the 2022-37 Corrective Action Plan, Gainwell activated the termination job within the PMM that automatically ends a provider’s contract with VT Medicaid when no license was obtained by the license end date. This termination job was activated on 06/05/23. 2. With the 2022-37 Corrective Acti...

1. With the 2022-37 Corrective Action Plan, Gainwell activated the termination job within the PMM that automatically ends a provider’s contract with VT Medicaid when no license was obtained by the license end date. This termination job was activated on 06/05/23. 2. With the 2022-37 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. The State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. Completed 2. Completed Contacts for Corrective Action Plan: Deidra Jarvis, DVHA Member and Provider Services deidra.jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384910 (2023-030)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG...

Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (ALN 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG conducted additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally and reemphasized the FFATA compliance regulations. This ensured the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. The results of the 2023 finding show that the departments understood the training materials and complied with the requirements to report. Although not timely, regarding the reporting in FY2023, the FY2024 should yield timeliness because of the prior year corrective action completion that was closed on 04/11/2023. On at least an annual basis, IAG conducts a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency’s procedures are up to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: December 31, 2023: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384905 (2023-028)

Significant Deficiency 2023

State of Vermont

VT

Eligibility Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

With the 2022-36 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax stan...

With the 2022-36 Corrective Action Plan, Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. The State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Deidra Jarvis, DVHA Supervisor of Member and Provider Services deidra.jarvis@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384904 (2023-027)

Significant Deficiency 2023

State of Vermont

VT

Procurement, Suspension & Debarment Eligibility Significant Deficiency § 200.303

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for clos...

The case was mistakenly closed on 6/30/23 based on non-response to an income verification request. A verification notice was sent 6/12/2023. The member did not respond to this notice. The member should then have received notice of termination effective 7/31/2023. The case was not processed for closure and appropriate notice was not sent because a system error caused this member to be classified as a new applicant instead of enrollee. This was likely due to case-specific circumstances of timing and household eligibility (other members were no longer eligible for Medicaid). Further, because they were classified as a new applicant, they received an additional verification notice (even though coverage was already terminated) and were ultimately “denied” for non-response in late July. As corrective action, we reinstated CHIP back to 7/1/2023 through 10/31/2023 after sending proper closure notice for failure to respond. Based on our internal QA process, Medicaid Recon and HCQC unit’s internal case reviews, no other incidents of this condition were found as of 10/2/2023. Scheduled Completion Date of Corrective Action Plan: Completed Contacts for Corrective Action Plan: Nicole McAllister, DVHA-HAEEU HCAA II nicole.mcallister@vermont.gov Sarah York, DVHA-HAEEU HCAA I sarah.york@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384903 (2023-026)

Significant Deficiency 2023

State of Vermont

VT

Questioned Costs Eligibility Student Financial Aid § 200.303

DCF has updated the eligibility determination procedure document and referenced checklists to ensure that there are additional reviews of the manual data entry and its processing in the data system (SSMIS). There is a process in place by which any cases where manual data entry causes erroneous IV-E ...

DCF has updated the eligibility determination procedure document and referenced checklists to ensure that there are additional reviews of the manual data entry and its processing in the data system (SSMIS). There is a process in place by which any cases where manual data entry causes erroneous IV-E draws, the Department will make changes in the data system and return IV-E funds erroneously claimed within one quarter of the mistake being identified. Scheduled Completion Date of Corrective Action Plan: January 1, 2024 Contact for Corrective Action Plan: Gillie Hopkins, DCF-FSD Permanency Planning Program Manager gillie.hopkins@vermont.gov Barbara Joyal, DCF-FSD System of Care Unit Director barbara.joyal@vermont.gov Beth Sausville, DCF-FSD System of Care Unit Director beth.sausville@vermont.gov Ed Dwinell, DCF Business Office, Financial Director ed.dwinell@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960 Questioned Costs: $1

Finding 384902 (2023-025)

Significant Deficiency 2023

State of Vermont

VT

Procurement, Suspension & Debarment Significant Deficiency § 200.303 § 200.324

The Division Administrator and the Division Director will create a central location for all supporting procurement documentation related to the division. This documentation will include but is not limited to the original RFP, bids, award selection criteria and bid review. Procurement documentation w...

The Division Administrator and the Division Director will create a central location for all supporting procurement documentation related to the division. This documentation will include but is not limited to the original RFP, bids, award selection criteria and bid review. Procurement documentation will be stored electronically according to the most current records retention schedule and be made available for review upon request. Scheduled Completion Date of Corrective Action Plan: 3/1/2024 Contacts for Corrective Action Plan: Danielle Tucker, VDH Division Administrator danielle.tucker@vermont.gov William Moran, VDH Division Director william.moran@vermont.gov Megan Hoke, VDH Financial Director megan.hoke@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384899 (2023-023)

Significant Deficiency 2023

State of Vermont

VT

Cash Management Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.514

The Agency of Human Services receives funding under ALN 93.568 and is responsible for reporting the federal interest liability for this program to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Management for notification of ...

The Agency of Human Services receives funding under ALN 93.568 and is responsible for reporting the federal interest liability for this program to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Management for notification of the annual interest rate. Going forward, the Agency of Human Services will obtain the annual interest rate directly from the CMIA website: Cash Management Improvement Act - Annual Interest Rates (treasury.gov). The Department of Finance and Management will also verify the Agency of Human Services’ submission prior to submitting the CMIA Annual Report to the US Department of the Treasury. Position Responsible for Implementation of Corrective Action Candace Elmquist Financial Director Candace.Elmquist@vermont.gov Peter Moino Director of Internal Audit Peter.Moino@vermont.gov Date of Implementation of Corrective Action: Completed: 2/6/2024

View Audit 297960

Finding 384895 (2023-021)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put...

Due to staff vacancies and turnover that arose in the DCF Quality Assurance & Reporting (QA&R) team during the summer of 2022, there was insufficient intra-team communication and training regarding FFATA reporting requirements. As of January 1, 2024, then, formal procedures and training will be put in place to ensure all QA&R staff are prepared to execute their responsibilities pertaining to FFATA reporting requirements. Further, in order to monitor FFATA reporting compliance going forward, AHS Internal Audit Group (IAG) will include LIHEAP subawards in its annual review. Scheduled Completion Date of the Corrective Action Plan: January 1, 2024: FFATA reporting procedures and training in place and operating. December 31, 2024: Annual review of FFATA rules and regulations including subawards review. Contacts for Corrective Action Plan: Melanie Rutledge, DCF Financial Director I melanie.rutledge@vermont.gov Megan Smeaton, DCF Financial Director IV megan.smeaton@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

View Audit 297960

Finding 384875 (2023-016)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we s...

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we started reconciliations and plan to continue reconciling a couple times each year. The work will be done by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. We will look into the Batch upload process to allow for data to be entered into the system easier. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 5/01/2024

View Audit 297960

Finding 384856 (2023-008)

Significant Deficiency 2023

State of Vermont

VT

Allowable Costs / Cost Principles Period of Performance Subrecipient Monitoring § 200.303 § 200.308 § 200.309 § 200.403

The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a...

The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a large number of personnel changes and shifts. The position that was responsible for the majority of these duties retired in January 2024. We proactively hired for her replacement a year before she retired. Over the course of the year our replacement took over more and more duties. In the process of this replacement, we have completed a tremendous amount of evaluation of our assigned duties, processes, workflow, training, and documentation. Not only in this role, but we are also undergoing a division and business unit wide analysis of our internal controls and workflow. It should also be noted that the UI admin funds are considered ‘formula funds’ from the US DOL. We are expected to run this program year-round with no gaps in service or performance. The funding that we receive from US DOL is based on an antiquated formula that breaks down the amount that is budgeted by Congress between 52 state and territories. We generally do not receive enough funding for the entire year. Also, with the recent trend of Congress to utilize the tool of the Continuing Resolution our funding is often ambiguous until most of the program year is over. We have at times seen our funding cut once a budget had been passed by Congress even though there was only about 3 months left in the program year. We are still expected to run this program and ‘find other sources of funding’. This does make the adherence to the period of performance challenging. However, as we evaluate our internal controls and procedures over the coming months, we will make note of every opportunity to strengthen this function to ensure that all charges applied to program funds are relevant, within the period of performance of the award, and are correctly reviewed and signed. Cameron Wood, UI Director, Cameron.Wood@vermont.gov Scheduled Completion Date of Corrective Action Plan: August 31, 2024

View Audit 297960

Finding 384836 (2023-003)

Significant Deficiency 2023

State of Vermont

VT

Subrecipient Monitoring Reporting School Nutrition Programs § 200.303

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we s...

To address the accuracy and timeliness of our entries into the FFATA system, we will use the USASPENDING.GOV website to assist us in reconciling what has been entered into the FFATA system. This will allow us to ensure that our grant ledgers agree with what is entered into FFATA. In March 2023 we started reconciliations and plan to continue reconciling a couple times each year. The work will be done by the Deputy CFO or position assigned by the Deputy CFO. We will also implement a process that will have all the steps necessary for a grant award or an amendment to ensure it is posted properly within our internal files and the external systems. This will ensure that new awards and amendments get routed and entered in the FFATA system timely. We will look into the Batch upload process to allow for data to be entered into the system easier. Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 5/01/2024

View Audit 297960

Finding 384799 (2023-002)

Significant Deficiency 2023

Newport News Redevelopment and Housing Authority

VA

HUD Housing Programs Eligibility Significant Deficiency

2023-002 Section 8 Project-Based Cluster – Assistance Listing No. 14.249/14.182 Recommendation: We recommend the Authority reinforce the individuals completing eligibility determinations with additional training and supervision as well as re-emphasize the controls and procedures that should be follo...

2023-002 Section 8 Project-Based Cluster – Assistance Listing No. 14.249/14.182 Recommendation: We recommend the Authority reinforce the individuals completing eligibility determinations with additional training and supervision as well as re-emphasize the controls and procedures that should be followed when completing the determinations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Housing will ensure property management staff is properly trained and supervised to ensure eligibility determinations are completed correctly. Name(s) of the contact person(s) responsible for corrective action: Director of Housing Planned completion date for corrective action plan: June 30, 2024

View Audit 297906

Finding 384790 (2023-006)

Significant Deficiency 2023

Newport News Redevelopment and Housing Authority

VA

HUD Housing Programs Internal Control / Segregation of Duties Reporting

2023-006 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their PIC upload process to ensure that all certifications are properly uploaded. Explanation of disagreement with audit finding: There is no disagreement with the audit f...

2023-006 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their PIC upload process to ensure that all certifications are properly uploaded. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Public and Assisted Housing Compliance Officer will ensure the PIC upload process is done properly. Name(s) of the contact person(s) responsible for corrective action: Director of Housing Planned completion date for corrective action plan: June 30, 2024

View Audit 297906

Finding 384786 (2023-001)

Significant Deficiency 2023

Newport News Redevelopment and Housing Authority

VA

HUD Housing Programs Eligibility Significant Deficiency

2023-001 Low-Rent Public Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reinforce the individuals completing eligibility determinations with additional training and supervision as well as re-emphasize the controls and procedures that should be followed when comple...

2023-001 Low-Rent Public Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reinforce the individuals completing eligibility determinations with additional training and supervision as well as re-emphasize the controls and procedures that should be followed when completing the determinations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Housing will ensure property management staff is properly trained and supervised to ensure eligibility determinations are completed correctly. Name(s) of the contact person(s) responsible for corrective action: Director of Housing Planned completion date for corrective action plan: June 30, 2024

View Audit 297906

Finding 384770 (2023-002)

Significant Deficiency 2023

Legacy Medical Care Inc.

IL

Significant Deficiency Internal Control / Segregation of Duties

Action taken in response to finding: • LMC staff will institute a monthly review of ten self-pay encounters and will provide training to staff as needed.

View Audit 297887

Finding 384769 (2023-005)

Significant Deficiency 2023

Housing Authority of the City of Martinsburg

WV

HUD Housing Programs Reporting Significant Deficiency

Finding 2023-005 - Special Tests and Provisions - SEMAP reporting ALN 14.871- Noncompliance & Significant Deficiency Corrective Action Plan: Training and procedures are being put in place for tenant file reviews and inspections. An experienced Executive Directo r has been hired who will ensure staf...

Finding 2023-005 - Special Tests and Provisions - SEMAP reporting ALN 14.871- Noncompliance & Significant Deficiency Corrective Action Plan: Training and procedures are being put in place for tenant file reviews and inspections. An experienced Executive Directo r has been hired who will ensure staff remain up to date with HUD compliance in order to ensure accurate reporting. Person Responsible: John Sales, Interim Executive Director Anticipated Completion Date: per HUD ongoing for five years

View Audit 297881

Finding 384768 (2023-004)

Significant Deficiency 2023

Housing Authority of the City of Martinsburg

WV

HUD Housing Programs Significant Deficiency Special Tests & Provisions

Finding 2023-004 - Housing Choice Voucher Tenant Files - Rent Calculations ALN 14.871- Noncompliance & Significant Deficiency Corrective Action Plan: Staff attended training Dec 2023. Process & procedures for Utility and other factor s are being put ln place. Person Responsible: John Sales, Interi...

Finding 2023-004 - Housing Choice Voucher Tenant Files - Rent Calculations ALN 14.871- Noncompliance & Significant Deficiency Corrective Action Plan: Staff attended training Dec 2023. Process & procedures for Utility and other factor s are being put ln place. Person Responsible: John Sales, Interim Executive Director Anticipated Completion Date: March 31, 2024

View Audit 297881

Finding 384695 (2023-003)

Significant Deficiency 2023

Independent School District No. 197

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties School Nutrition Programs

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.555, 10.559, 10.556, AND 10.553 2023-003 Internal Control Over Compliance With Federal Suspension and Debarment R...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.555, 10.559, 10.556, AND 10.553 2023-003 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Summary of Finding Criteria – 2 CFR § 180 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster program. Condition – The District did not have sufficient controls in place within its child nutrition cluster program to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review its policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – Peter Olson-Skog, the District’s Superintendent. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Peter Olson-Skog, the District’s Superintendent, will ensure appropriate controls are in place to verify that any vendor with which the District contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.

View Audit 297807

Finding 384694 (2023-007)

Significant Deficiency 2023

Columbia College

MO

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

2023-007 Exit Counseling (Significant Deficiency) Criteria: Federal regulations stipulate that an institution must ensure that exit counseling is conducted with each Federal Direct Loan borrower shortly before the student borrower ceases at least half-time study at the school. If a student borrower ...

2023-007 Exit Counseling (Significant Deficiency) Criteria: Federal regulations stipulate that an institution must ensure that exit counseling is conducted with each Federal Direct Loan borrower shortly before the student borrower ceases at least half-time study at the school. If a student borrower withdraws from the school without prior knowledge or fails to complete the exit counseling as required, exit counseling must, within 30 days after the school learns that the student has withdrawn from school or failed to complete the exit counseling as required, be provided either through interactive electronic means, by mailing written counseling materials to the student borrower at the student borrower’s last known address, or by sending written counseling materials to an email address provided by the student borrower that is not an email address associated with the school sending the counseling materials. Condition: During our testing, we noted eight instances, in a sample of nine students requiring exit counseling, in which evidence of exit counseling and notification of exit counseling could not be provided by the College. Action Taken: We concur with this finding. Currently, students receive a withdrawal notification that provides them with a link to complete their exit counseling. Moving forward and during the completion of the withdrawal, the students will be presented with an exit counseling digital page. On this page, withdrawal information will be provided to the student along with the deadline to complete the exit counseling. Students will also certify that they have received and understood the information. Once the withdrawal form is completed, students will get a follow up email that will also direct them to the exit counseling at www.studentaid.gov and inform them of the 30-day deadline. Responsible Party: Lola Kennedy, Senior Director of Financial Aid and Sharon Murphy, Registrar Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) and Sharon Murphy, Registrar (smurphy@columbiasc.edu) Expected date of correction: April 1, 2024

View Audit 297799

Finding 384693 (2023-006)

Significant Deficiency 2023

Columbia College

MO

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

2023-006 Return of Title IV Funds (Significant Deficiency) Criteria: When a recipient of Title IV grant or loan assistance withdraws from a school during a payment period in which the recipient began attendance, the school must determine the amount of Title IV assistance earned by the student as of ...

2023-006 Return of Title IV Funds (Significant Deficiency) Criteria: When a recipient of Title IV grant or loan assistance withdraws from a school during a payment period in which the recipient began attendance, the school must determine the amount of Title IV assistance earned by the student as of the student’s withdrawal date. If the total of the Title IV assistance earned by the student is less than the amount that was distributed to the student, the difference must be returned to the Title IV programs. A school must return Title IV funds to the programs from which the student received aid as soon as possible but no later than 45 days after the date of determination of a student’s withdrawal. Condition: From a population of 61 students that withdrew during the fiscal year, we tested seven and noted that six of the seven required a refund calculation and return of funds. Four of the students refund calculations were not completed in a timely fashion and two students that completed a withdrawal form did not have a refund calculations prepared. The College did not return Title IV funds for the two students that should have had refund calculations and the College did not return Title IV funds within 45 days after the date of determination of the student’s withdrawal for the four students that had refund calculations prepared. Action Taken: We concur with this finding. During the 2022-2023 academic year, the Office of Financial Aid experienced much transition. The office is now fully staffed. In addition, the communication list for withdrawals was updated with the Director of Financial Aid’s information to ensure the financial aid office receives all withdrawal information in a timely manner. Responsible Party: Lola Kennedy, Senior Director of Financial Aid Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) Expected date of correction: July 2023

View Audit 297799

Finding 384692 (2023-005)

Significant Deficiency 2023

Columbia College

MO

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

2023-005 Reporting Student Withdraw Date in the National Student Loan Data System (NSLDS) (Significant Deficiency) Criteria: The College is responsible for submitting timely, accurate and complete responses to Enrollment Reporting roster files and for maintaining proper documentation in accordance ...

2023-005 Reporting Student Withdraw Date in the National Student Loan Data System (NSLDS) (Significant Deficiency) Criteria: The College is responsible for submitting timely, accurate and complete responses to Enrollment Reporting roster files and for maintaining proper documentation in accordance with 34 CFR Section 685.309(a)(2). Condition: From a population of 61 students that withdrew during the fiscal year, we tested seven and noted that six of the seven required a refund calculation and return of funds. The change in status was not reported to NSLDS for one student and the last date of the semester was reported instead of the withdrawal date for four students. Action Taken: The Registrar’s Office maintains the institution’s enrollment records. During the fall of 2023, the enrollment reporting process was moved to the Registrar’s Office to ensure the accuracy of reporting. Responsible Party: Sharon Murphy, Registrar Point of Contact: Sharon Murphy, Registrar (smurphy@columbiasc.edu) Expected date of correction: August 2023

View Audit 297799

Finding 384691 (2023-004)

Significant Deficiency 2023

Columbia College

MO

Student Financial Aid Significant Deficiency

2023-004 Incorrect Calculation of Title IV Funds Refunds (Significant Deficiency) Criteria: The total number of calendar days in a payment period or period of enrollment includes all days within the period that a student was scheduled to complete, except that scheduled breaks of at least five consec...

2023-004 Incorrect Calculation of Title IV Funds Refunds (Significant Deficiency) Criteria: The total number of calendar days in a payment period or period of enrollment includes all days within the period that a student was scheduled to complete, except that scheduled breaks of at least five consecutive days are excluded from the total number of calendar days in a payment period or period of enrollment and the number of calendar days completed in that period. If a student withdrawals by providing notification to designated officials, the withdrawal date is the date notification was provided. Institutional charges used in the refund calculation are the charges that were initially assessed the student for the entire payment period. Condition: From a population of 61 students that withdrew during the fiscal year, we tested seven and noted that four of the seven had refund calculations prepared. From these calculations we noted the following: 1. Breaks of five or more consecutive days were not deducted from total days in all refunds. 2. The date of the college’s determination was used as the withdrawal date for three of the four students.3. Institutional charges for the period used in the refund calculations included tuition and fee credits processed due to the withdrawal for two of the four students. Action Taken: We concur with this finding. During the 2022-2023 academic year, the Office of Financial Aid experienced much transition. The office is now fully staffed. In addition, the staff attend internal and external training on R2T4 processing along with other regulations. System updates are performed during the Fall semester for the next year. During this update, R2T4 parameters are set and monitored to ensure accuracy. In addition, the R2T4 calculations now include adjustments made to the students’ account at the time of withdrawal. Responsible Party: Lola Kennedy, Senior Director of Financial Aid Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) Expected date of correction: August 1, 2023

View Audit 297799

Finding 384690 (2023-003)

Significant Deficiency 2023

Columbia College

MO

Student Financial Aid Significant Deficiency

2023-003 Treatment of a student who fails to receive a passing grade in any class (Significant Deficiency) Criteria: An institution must have a procedure for determining whether a Title IV aid recipient who began attendance during a period completed the period or should be treated as a withdrawal. I...

2023-003 Treatment of a student who fails to receive a passing grade in any class (Significant Deficiency) Criteria: An institution must have a procedure for determining whether a Title IV aid recipient who began attendance during a period completed the period or should be treated as a withdrawal. If a student who began attendance and has not officially withdrawn fails to earn a passing grade in at least one course offered over an entire period, the school must assume, for Title IV purposes, that the student has unofficially withdrawn, unless the institution can document that the student completed the period. In the absence of evidence of a last day of attendance, a school must consider a student who failed to earn a passing grade in all classes to be an unofficial withdrawal. Condition: From a population of 140 students that received all failing grades in a term, we tested fourteen students and noted that documentation of the last date of attendance could not be provided for any of the students tested. Action Taken: We concur with this finding. With enhancements to the Jenzabar ONE system, the institution has implemented a new process that requires professors to enter the Last Day of attendance (LDA) for any student who earned an F grade. Going forward, the Registrar will present a report to the Office of Financial Aid two days after final grades post for the semester. The report will have the students who have all Fs with their LDS listed for each class. Responsible Party: Lola Kennedy, Senior Director of Financial Aid Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) Expected date of correction: April 2024

View Audit 297799

Finding 384689 (2023-002)

Significant Deficiency 2023

Columbia College

MO

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

2023-002 Disbursement of Title IV Funds (Significant Deficiency) Criteria: An institution must disburse during the current payment period, with certain qualifying exceptions, the amount of Title IV, HEA program funds that a student enrolled at the institution, or the student’s parent, is eligible to...

2023-002 Disbursement of Title IV Funds (Significant Deficiency) Criteria: An institution must disburse during the current payment period, with certain qualifying exceptions, the amount of Title IV, HEA program funds that a student enrolled at the institution, or the student’s parent, is eligible to receive for that payment period, 34 CFR 668.164(b)(1). Condition: During our testing, we noted three instances in a sample of 26 students in which Direct Loan awards were not disbursed to the student during the payment period. Qualified exceptions were not met and the three students received disbursements for the 2022-2023 academic year on August 14, 2023. Action Taken: We concur with this finding. During the 2022-2023 academic year, the Office of Financial Aid experienced much transition. The office is now fully staffed. In addition, the staff attend internal and external training sessions regularly. Currently, disbursements are processed at least 3 times a week. The Office of Financial Aid works diligently to ensure all funds are fully disbursed by the end of each semester. Responsible Party: Lola Kennedy, Senior Director of Financial Aid Point of Contact: Lola Kennedy, Senior Director of Financial Aid (lkennedy@columbiasc.edu) Expected date of correction: January 2024

View Audit 297799

Finding 384683 (2023-004)

Significant Deficiency 2023

Gila Crossing Community School

AZ

Reporting Significant Deficiency Program Income

Finding Number: 2023‐004 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Indian School Equalization Program 15.042 Administrative Cost Grants for Indian Schools 15.046 COVID‐19 Education Stabilization Fund 84.425 Contact Person: Jim Mosley, Superintendent Anticipated Completion ...

Finding Number: 2023‐004 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Indian School Equalization Program 15.042 Administrative Cost Grants for Indian Schools 15.046 COVID‐19 Education Stabilization Fund 84.425 Contact Person: Jim Mosley, Superintendent Anticipated Completion Date: June 30, 2024 Planned Corrective Action: The School reported incorrect expenditures for one of four quarterly reports reviewed. Acknowledged that one of the quarterly SF‐425 reports did contain an error with the additional revenue and expenses of non‐federal monies included in the report. Future reports will be reviewed more closely to prevent such errors.

View Audit 297787

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