Corrective Action Plans

Finding 369359 (2023-002)

Significant Deficiency 2023

OK

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

Federal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend the Universi...

Federal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend the University review reporting processes to ensure all students that require exit counseling receive it in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Request a formal count of all graduates from Registrar at the end of each semester and review the number of exit counseling notifications sent from financial aid to ensure notifications are sent to all appropriate graduating students. Update procedures to reflect additional review. Name(s) of the contact person(s) responsible for corrective action: Dasha Smith Planned completion date for corrective action plan: 4/1/24

View Audit 290586

Finding 369355 (2023-001)

Significant Deficiency 2023

Oklahoma Panhandle State University

OK

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Federal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend that the Col...

Federal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend that the College 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: OPSU will communicate closely with OSU IT and the Office of Internal Audit regarding changes made at the system level to satisfy GLBA requirements. Name(s) of the contact person(s) responsible for corrective action: Elizabeth McMurphy and Dasha Smith Planned completion date for corrective action plan: May 2024

View Audit 290586

Finding 369351 (2023-001)

Significant Deficiency 2023

New Mexico Aging and Long-Term Services Department

NM

Cash Management Subrecipient Monitoring Significant Deficiency

Recommendation The Department should implement procedures to ensure compliance with the cost reimbursement nature of the grant and insure that all valid expenses have been incurred and supported for request for reimbursement. Management Response Corrective Action: Administrative Services Division...

Recommendation The Department should implement procedures to ensure compliance with the cost reimbursement nature of the grant and insure that all valid expenses have been incurred and supported for request for reimbursement. Management Response Corrective Action: Administrative Services Division (ASD) has processed the OPR for return of the $10,958 to the Department of Health. ALTSD will implement training for agency directors and other leaders who oversee and implement grant projects. This training will include the process for development of the initial budget allocations to appropriate categories grant procedures for requesting changes to the budget categories from the funder. The training will also include a process for streamlined communication between the director or manager and the ASD grant staff responsible for the financial controls. Timeline of Corrective Actions: Perform first training to any programmatic grant manager or involved staff by January 1, 2024. This will be ongoing any time a new grant award is received by the agency. Responsible Party(ies): Chief Financial Officer

View Audit 290577

Finding 369320 (2023-005)

Significant Deficiency 2023

Great Plains Food Bank

ND

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring

U.S. Department of Agriculture CFDA # 10.565, 10.568, 10.569 Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations for the CSFP and Emergency Food Assistance Programs. Responsible Individu...

U.S. Department of Agriculture CFDA # 10.565, 10.568, 10.569 Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations for the CSFP and Emergency Food Assistance Programs. Responsible Individuals: Melissa Sobolik, CEO and David Stachon, CFO Corrective Action Plan: The GPFB will ensure all documents for TEFAP and CSFP programs have proper signatures by necessary parties going forward. An electronic signature process has been implemented to make the dissemination, review and storage of this process easier. Anticipated Completion Date: Immediate

View Audit 290553 Questioned Costs: $1

Finding 369186 (2023-004)

Significant Deficiency 2023

Oklahoma State University

OK

Procurement, Suspension & Debarment Significant Deficiency § 200.303

US Department of Education: Education Stabilization Fund - Assistance Listing 84.425F Recommendation: We recommend the University review procedures to monitor and retain documentation for suspension and debarment verification. Explanation of disagreement with audit finding: There is no disagreement...

US Department of Education: Education Stabilization Fund - Assistance Listing 84.425F Recommendation: We recommend the University review procedures to monitor and retain documentation for suspension and debarment verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The University is already utilizing Visual Compliance to assess all vendors for suspension and debarment but will obtain and document the review of the SOC 2 report for Visual Compliance annually. Name(s) of the contact person(s) responsible for corrective action: Scott Schlotthauer, Chief Procurement Officer. Planned completion date for corrective action plan: Immediately.

View Audit 290482

Finding 369128 (2023-003)

Significant Deficiency 2023

Oklahoma State University

OK

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

US Department of Education: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.038, 84.063, 84.268, 84.379, 84.033 Recommendation: CLA recommends that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disag...

US Department of Education: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.038, 84.063, 84.268, 84.379, 84.033 Recommendation: CLA recommends 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 planned/taken in response to finding: OSU is creating a GLBA management program to govern security of GLBA data and ensure compliance with associated requirements. Name(s) of the contact person(s) responsible for corrective action: Aaron Smith, Director of Information Security Services/Information Security Officer. Planned completion date for corrective action plan: March 31, 2024

View Audit 290482

Finding 369107 (2023-002)

Significant Deficiency 2023

Oklahoma State University

OK

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

US Department of Education: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.033 Recommendation: CLA recommends OSU OKC and OSUIT review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported timely and accurately...

US Department of Education: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.033 Recommendation: CLA recommends OSU OKC and OSUIT review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported timely and accurately Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: OSU OKC: The Director of Financial Aid, Registrar, and Sr Director of Institutional Effectiveness developed a new process on reporting first of term, end of term, updates to enrollment, and processing errors in a timely manner. In addition, the Director of Financial Aid also added a step to the current OSU OKC R2T4 process. Financial Aid counselors will also be checking NSLDS on all students who populate on our R2T4 listing. Monthly, the Director of Financial Aid will select a small population to R2T4 and audit the information reported in NSLDS to ensure the new process is working correctly. OSUIT: OSUIT will shorten the dates for reporting to the NSLC to make sure the NSLC has sufficient time to report to NSLDS. Name(s) of the contact person(s) responsible for corrective action: OSU OKC: Elizabeth Lucas, Director of Financial Aid and Scholarships; Hank Lankford, Registrar; and Nick Irby, Senior Director of Institutional Effectiveness and Accreditation. OSUIT: Matt Short, Director of Financial Aid and Scholarships; and Crystal Palacioz, Registrar. Planned completion date for corrective action plan: OSU OKC: The completion date for the enrollment reporting has been implemented since the end of September 2023. The additional financial aid processes were implemented in October 2023 and will be fully completed by December 1, 2023. OSUIT: December 1, 2023.

View Audit 290482

Finding 369088 (2023-001)

Significant Deficiency 2023

Oklahoma State University

OK

Procurement, Suspension & Debarment Significant Deficiency § 200.303

US Department of Education: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.033 Recommendation: CLA recommends OSU CHS and OSUIT evaluate its procedures around disbursements of loans and ensure documentation is properly retained. Explanation of disagreement ...

US Department of Education: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063, 84.268, 84.033 Recommendation: CLA recommends OSU CHS and OSUIT evaluate its procedures around disbursements of loans and ensure documentation is properly retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: OSU CHS: Financial aid staff have added a process to Banner to automatically generate a notification e-mail to students when loans are disbursed. OSUIT: The query that OSUIT runs to send emails to the students and reports the results to OSUIT Financial Aid staff has been changed from reporting one term at a time to report disbursements from any term as long as the change in a prior term happens within the last 24 hours. In addition, staff will be retrained on how to review the reports and the reports will now go to all Financial Aid staff so that multiple staff may review reports. Name(s) of the contact person(s) responsible for corrective action: OSU CHS: Jeff Hackler, Associate Dean for Enrollment Management. OSUIT: Matt Short, Director of Financial Aid and Scholarships. Planned completion date for corrective action plan: OSU CHS: Already implemented. OSUIT: December 1, 2023.

View Audit 290482

Finding 369084 (2023-002)

Significant Deficiency 2023

Easter Seals Serving Dc/md/va

MD

Reporting Significant Deficiency Equipment & Real Property Management

The status of real property purchased, constructed, or subject to major renovations paid for in whole or in part with federal Head Start funds must be reported annually on standard forms (SF) Real Property Status Reports 429 and SF-429-A. Based on our grant agreement for our Early Head Start Program...

The status of real property purchased, constructed, or subject to major renovations paid for in whole or in part with federal Head Start funds must be reported annually on standard forms (SF) Real Property Status Reports 429 and SF-429-A. Based on our grant agreement for our Early Head Start Program in Washington, DC , as well as construction activities undertaken throughout Fiscal Year 2023 related to the facility located at 1151 Bladensburg Road, NE, Easter Seals DC | MD | VA is required to file the aforementioned forms no later than 90 days after the program year ends. As noted in the audit report, our organization did not file the required SF-429 Form for the latest program year (FY 2023) for our Washington DC EHS program. The director for the Head Start program was aware of the Real Property Status filing requirement, but apparently misunderstood that the deadline for the Year 2 (FY 2023) filing was September 30, 2023. We anticipate that the required reports will be submitted to the appropriate governing agency by March 31, 2024.

View Audit 290474

Finding 369077 (2022-007)

Significant Deficiency 2023

Wheeling Jesuit University INC

WV

Reporting Significant Deficiency Internal Control / Segregation of Duties

FINDING 2022 – 007 Repeat of Prior Year Finding 2021-011 Type of Finding: Significant Deficiency - Reporting Federal Award Program: COVID – 19 Higher Education Emergency Relief Fund (HEERF) Student Aid Portion and COVID – 19 HEERF Institutional Portion Federal Agency: U.S. Department of Education As...

FINDING 2022 – 007 Repeat of Prior Year Finding 2021-011 Type of Finding: Significant Deficiency - Reporting Federal Award Program: COVID – 19 Higher Education Emergency Relief Fund (HEERF) Student Aid Portion and COVID – 19 HEERF Institutional Portion Federal Agency: U.S. Department of Education Assistance Listing Number: 84.425E, 84.425F Federal Award Year: June 30, 2022 Name of responsible Individual: C.F.O., Gregory Bloomfield Criteria: Reporting: The University was required to submit to the Department of Education an annual report of its HEERF expenditures using the Annual Report Data Collection System by May 6, 2022. Additionally, the institution is required to post accurate and completed quarterly HEERF information to its primary website. Condition: The annual report was not completed or submitted. Additionally, certain amounts reported on submitted quarterly reports did not reconcile to underlying supporting documentation. Corrective Action: The University will formalize and document financial processes to establish internal controls in order to ensure accurate, timely and consistent reporting. In addition, this will create a reasonable transition plan during employee turnover, as well as ensure proper and timely filings. Anticipated Completion Date: Full implementation and documentation with current staffing is currently in process and estimate completion by March 31, 2024, however, HEERF has since ended so no further reporting is necessary.

View Audit 290469

Finding 369073 (2022-002)

Significant Deficiency 2023

Wheeling Jesuit University INC

WV

Student Financial Aid Reporting Significant Deficiency

FINDING 2022 – 002: Repeat of Prior Year Finding 2021-004 Name of Responsible Individual: Joyce Lubeck-Sonenberg, Acting Director of Financial Aid Type of Finding: Federal Award Findings and Questioned Costs Criteria: Recipients of federal awards are required to administer its federal programs with ...

FINDING 2022 – 002: Repeat of Prior Year Finding 2021-004 Name of Responsible Individual: Joyce Lubeck-Sonenberg, Acting Director of Financial Aid Type of Finding: Federal Award Findings and Questioned Costs Criteria: Recipients of federal awards are required to administer its federal programs with an adequate system of internal controls over applicable compliance requirements. Condition: The University did not reconcile its SAS data file to its financial records for all 12 months of the fiscal year. Corrective Action: Wheeling University has implemented several significant corrective actions towards improving the reconciliation requirements for the Pell and Direct Loan Programs. A highly administratively capable staff person has been promoted to Assistant Director and demonstrates a level of financial aid leadership that is appreciated throughout the campus community. This individual has received extensive regulatory and technical training regarding the federal requirements to monthly reconcile cash received from the G5 account with disbursements submitted to the COD System. In addition to confirming the accuracy of monthly reconciliation efforts, this approach allows the FA office to compare internal awarding databases against COD’s database for Pell and Direct Loan awards and identify discrepancies that require further attention. Also, this assists the University to be better prepared to perform efficient and accurate closeout activities at year-end. Previous audit findings showed little evidence of accurate reconciliation efforts. In working with the University IT Department, monthly reconciliation files are now housed in a shared electronic file system, easily retrieved for review, and are confirmed for accuracy by the acting Director of Financial Aide each month. Anticipated Completion Date: This process was completed in March of 2023 and is ongoing.

View Audit 290469

Finding 369072 (2022-006)

Significant Deficiency 2023

Wheeling Jesuit University INC

WV

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

FINDING 2022 – 006: Type of Finding: Significant Deficiency-Return of Title IV Funds Name of Responsible Individual: Joyce Lubeck-Sonenberg, Acting Director of Financial Aid Criteria: Title IV regulations (34 CFR 668.22) require the University to return the unearned portion of grants or loans to the...

FINDING 2022 – 006: Type of Finding: Significant Deficiency-Return of Title IV Funds Name of Responsible Individual: Joyce Lubeck-Sonenberg, Acting Director of Financial Aid Criteria: Title IV regulations (34 CFR 668.22) require the University to return the unearned portion of grants or loans to the student based the calculated percent completed by the student. Condition: Calculations of return of funds for certain students selected for testing were not completed and therefore refunds were not made. Corrective Action: Audit results identify several Wheeling University Financial Aid R2T4 calculations that were found to be incomplete, inaccurate, or not completed within an acceptable time frame as required by regulations. The apparent cause of these findings was a lack of administrative capability, staff turnover, and a general lack of a systematic process for completing accurate R2T4 calculations. Since these findings were first noted, the Wheeling University Financial Aid Office has added competent staff and has provided sufficient training and supervised experience to ensure R2T4 calculations are completed within the regulatory guidelines. The acting Director of Financial Aid has taken steps to ensure to inform the campus community of the Department’s philosophy of an “institutional responsibility” regarding regulatory compliance with Title IV programs, and this is particularly true in the matter of student FA eligibility with enrollment, attendance, and withdrawal. As such, the acting Director of Financial Aid has worked closely with the University Registrar to ensure there is a clear understanding that if a recipient of Title IV grant or loan funds withdraws from the University after beginning attendance, the FA Office must perform an R2T4 calculation to determine the amount of Title IV assistance earned by the student. Since withdrawal information is critical to R2T4 calculations, a Withdrawal Report has been developed to better capture withdrawal data. This report is updated and reviewed by the FA Director (three times per week) to confirm the accuracy of such data. In addition, all R2T4 calculations are completed on the University's internal software (Colleague) rather than DOE software and follow an updated, more clearly defined R2T4 policy. Anticipated Completion Date: This process was completed September of 2023 and is ongoing.

View Audit 290469

Finding 369066 (2023-002)

Significant Deficiency 2023

Moberly Area Community College

MO

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

2023-002 US Department of Education Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College review its current procedures for Title IV funds and implement additional procedures to ensure refunds are returned timely. Explanation of disa...

2023-002 US Department of Education Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College review its current procedures for Title IV funds and implement additional procedures to ensure refunds are returned timely. Explanation of disagreement with audit finding: MACC is an attendance taking institution and our regular practice requires review of attendance records two to three times per week. When the Financial Aid Office discovers students have withdrawn from classes, we review and calculate an R2T4 when required - usually within 1-5 days from the date it is discovered. This finding of a "late return" is due to a faculty member dropping a student outside of the dates required by our attendance policy. I would like to note that the R2T4 was performed timely and accurately as soon as the drop was identified. Action taken in response to finding: The issue was reported to the President, Vice Presidents, and Deans; as a result, the faculty were addressed and reminded of the importance to comply with the college's attendance policy. Name(s) of the contact person(s) responsible for corrective action: Amy Hager Planned completion date for corrective action plan: Our Vice President for Instruction will provide reminders of our policy with our faculty each semester. In the event that a faculty member does not comply with the attendance policy, their Dean will take disciplinary action.

View Audit 290466

Finding 369065 (2023-001)

Significant Deficiency 2023

Moberly Area Community College

MO

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

2023-001 US Department of Education Student Financial Assistance Cluster - Assistance Listing No. 84.063 Recommendation: We recommend that the student financial aid department work to ensure disbursements are reported to COD within 15 days of the disbursement date. Explanation of disagreement with...

2023-001 US Department of Education Student Financial Assistance Cluster - Assistance Listing No. 84.063 Recommendation: We recommend that the student financial aid department work to ensure disbursements are reported to COD within 15 days of the disbursement date. Explanation of disagreement with audit finding: As a standard, regular practice, communicates disbursement information for Federal Pell and Federal loans to COD no less than once per week; therefore, we believe we have an adequate way to report disbursements to COD within 15 days of the disbursement date. MACC transitioned to new financial aid processing software (Jenzabar Financial Aid - JFA) in summer 2022 while other areas of the college were still using the "old" system (Jenzabar CX). We experienced a glitch during the transition in which the files did not update as expected, we worked with our software vendor to correct the issue. Below is the timeline of action taken:This finding pertains to one student with Sub and Unsub Loans. We posted aid and sent the original batch on Friday, 07/15/2022; we discovered the issue on Wednesday, 07/20/2022, and reached out to Jenzabar immediately; we followed up with Jenzabar on Thursday, 07/28/2022 because the records were not updated; the records were updated on Monday, August 1. Action taken in response to finding: MACC continues to submit disbursement information at least once per week and review student details for posting accuracy. We took the necessary steps to fix the issue. Name(s) of the contact person(s) responsible for corrective action: Amy Hager Planned completion date for corrective action plan: We believe this finding was an anomaly due to the system conversion. We have no evidence of this happening since.

View Audit 290466

Finding 369051 (2023-001)

Significant Deficiency 2023

Orange County, North Carolina

NC

Allowable Costs / Cost Principles Reporting Cash Management

2023-001 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of contact person: Nancy Coston, Director of the Department of Social Services Department Response: DSS agrees that there were some discrepancies found between Daysheets and Kronos time....

2023-001 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of contact person: Nancy Coston, Director of the Department of Social Services Department Response: DSS agrees that there were some discrepancies found between Daysheets and Kronos time. Given the differences between the reporting deadlines for the two automated systems, it is highly unlikely that all staff time will ever match exactly. However, DSS will continue to use the reconciliation process outlined below. DSS Daysheets/Kronos Reconciliation Process Employees must enter their time into Daysheets by 5 pm on the following business day, unless special permission is obtained from the employee’s supervisor. Employees are responsible for ensuring that the minutes/hours reported on the Daysheets agree to their time reported in Kronos. When they certify their time in the Daysheets program, they are certifying that they have reconciled their Daysheet time to the Kronos system. On a weekly basis by Wednesday at noon, Supervisors must verify the Daysheet time reported for the prior week for each direct report and that it agrees to the Kronos recordkeeping reports for that period. Supervisors must keep records evidencing that this reconciliation has been completed. This documentation can be requested for review by the DSS Accounting staff and/or auditors at any time. On a monthly basis prior to uploading Daysheets to the State, Accounting unit staff will verify the Daysheet time reported for the month for all department staff (required to complete a Daysheet) and that it agrees to the Kronos recordkeeping reports for the period. Accounting unit staff will utilize Kronos and Daysheet systems generated reports in the verification process. Supervisors will be notified of any discrepancies and will have staff make the necessary corrections. Supervisors are responsible for counseling employees whose time in Daysheets do not agree to Kronos or for those who do not enter time within required timeframes without supervisor approval. On a monthly basis, according to the Daysheet Deadline Calendar provided by Accounting, each supervisor is responsible for approving the accuracy of the Daysheets in the Daysheets program. It is expected that the supervisor has properly reconciled the minutes and hours reported in the Daysheets to the Kronos system. Please note, in instances where Kronos time is rounded to the hundredth decimal, Daysheet time will not reconcile since it will result in partial minutes. In these instances, Daysheet minutes will be rounded up or down. Proposed Completion Date: January 1, 2024

View Audit 290460

Finding 367429 (2023-006)

Significant Deficiency 2023

Cleveland County

NC

Eligibility Significant Deficiency

Finding 2023-006 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs (continued) Lead Staff along with Supervision will conduct refresher training on how to run all required electr...

Finding 2023-006 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs (continued) Lead Staff along with Supervision will conduct refresher training on how to run all required electronic data matches and how to thoroughly document a case using the developed case note template. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Econ Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an ample amount of work in order to identify any error trends. The county is working toward specializing the Adult Medicaid by function within the Adult Program and will consist of one team that consist of a Intake Application team and a Redeterminationteam. The county currently has a targeted completion date of late spring 2024. Since many of these errors were found within the Adult Medicaid team the county feels that once specialization for this area is complete we will see a reduction of errors in this area. Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed.

View Audit 290432

Finding 367428 (2023-005)

Significant Deficiency 2023

Cleveland County

NC

Eligibility Significant Deficiency

Finding 2023-005 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medic...

Finding 2023-005 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed. Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period however a parent/caretaker can request assistance with establishing child support at which time the worker would assist by keing the referral. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and will continue to reduce as we go forward. Lead Staff along with Supervision will conduct refresher training on how to add evidence and update evidence to the Evidence Dashboard on a case. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Econ Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an ample amount of work in order to identify any error trends. The county is working toward specializing the Adult Medicaid by function within the Adult Program and will consist of one team that consist of a Intake Application team and a Redeterminationteam. The county currently has a targeted completion date of late spring 2024. While this is a repeat finding from 2022 it is important to note the significant decrease in the total number found in 2023 of one error compared to 8 errors found in 2022.

View Audit 290432

Finding 367427 (2023-004)

Significant Deficiency 2023

Cleveland County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2023-004 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2023-005 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings a...

Finding 2023-004 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Finding 2023-005 Name of Contact Person: Alice Wilson, Medicaid Program Administrator Corrective Action: Proposed Completion Date: Section III - Federal Award Findings and Questioned Costs Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed. Lead staff along with Supervision will condcut refresher training regarding when and how to properly send a IV D referral. The county must also ensure that staff is aware of current guidance in Admin letter 13-23 which states that an applicant/beneficiary is not required to cooperate with Child Support during the CCU period however a parent/caretaker can request assistance with establishing child support at which time the worker would assist by keing the referral. While this is a repeat finding it is important to note the decrease in errors found to one error in 2023 compared to 3 found in 2022. The county feels that the specialization model with in the Family & Childrens team has contributed to this reduction and will continue to reduce as we go forward. Lead Staff along with Supervision will conduct refresher training on how to add evidence and update evidence to the Evidence Dashboard on a case. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Econ Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an ample amount of work in order to identify any error trends. The county is working toward specializing the Adult Medicaid by function within the Adult Program and will consist of one team that consist of a Intake Application team and a Redeterminationteam. The county currently has a targeted completion date of late spring 2024. While this is a repeat finding from 2022 it is important to note the significant decrease in the total number found in 2023 of one error compared to 8 errors found in 2022. Staff training to be completed by 3/31/2024 Lead Staff along with Supervision will conduct refresher training on how to add and remove household members in a case. This area will continue to be a part of the second party checks conducted by lead staff and supervision to ensure accurate entry. Management along with the Medicaid Services Administrator will review the current second party/ QA Analysis policy and update any areas to ensure that supervisors and lead staff are sampling an appropriate amount of work in order to identify any error trends. The county is in the process of specializing all Medicaid staff by function within the program adminisitered. Currently the Family & Childrens Medicaid department has been specialized into a Intake Application team and a Redetermination team. The Adult Medicaid team is working toward this same specialization model with a target completion date of late spring 2024. While this is a repeat finding from 2022 it is important to note the significant decrease in the total number found in 2023 of one error compared to 10 errors found in 2022. Review of Second Party/QA policy and staff training to be completed by 3/31/2024. Specialization of Adult Medicaid group to be completed by 4/30/2024 if fully staffed.

View Audit 290432

Finding 367381 (2023-006)

Significant Deficiency 2023

City of Belmont

NC

Reporting Significant Deficiency Internal Control / Segregation of Duties

Significant Deficiency Finding 2023-006: Name of Contact Person: Jared Pyles, Finance Director Corrective Action: The City mistakenly reported budgeted costs rather than cumulative costs as part of the compliance reporting for ARPA Funds. The City will correct on its next reporting and will inclu...

Significant Deficiency Finding 2023-006: Name of Contact Person: Jared Pyles, Finance Director Corrective Action: The City mistakenly reported budgeted costs rather than cumulative costs as part of the compliance reporting for ARPA Funds. The City will correct on its next reporting and will include an additional layer of review to prevent future reporting errors. Proposed Completion Date: Immediately.

View Audit 290376

Finding 367379 (2023-003)

Significant Deficiency 2023

The Inner Voice, Inc.

IL

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Significant Deficiency

The procurement policy in accordance with uniform guidance was implemented on April 1, 2023. The policy will be reviewed and updated as needed on an annual basis.

View Audit 290359

Finding 367210 (2023-002)

Significant Deficiency 2023

Southern California Institute of Architecture

CA

Student Financial Aid Subrecipient Monitoring Cash Management

Finding number 2023-002 – Eligibility-Significant Deficiency Over Internal Controls Over Compliance Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action will be implemented in January 2024. The...

Finding number 2023-002 – Eligibility-Significant Deficiency Over Internal Controls Over Compliance Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action will be implemented in January 2024. The school's management agrees with the finding and has implemented procedure whereby the Financial Aid department will include the Student Identification and Expected Family Contribution (EFC) on the Work Study log to monitor awards against the student’s EFC.

View Audit 290324

Finding 367209 (2023-001)

Significant Deficiency 2023

Southern California Institute of Architecture

CA

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

Finding number 2023-001 – Special Tests and Provisions-Enrollment Reporting-Significant Deficiency Over Internal Controls Over Compliance Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action wa...

Finding number 2023-001 – Special Tests and Provisions-Enrollment Reporting-Significant Deficiency Over Internal Controls Over Compliance Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action was implemented in December 2023. The school's management agrees with the finding and has implemented procedure whereby changes in enrollment status reported to the National Student Clearinghouse will be sample reviewed by the Registrar within NSLDS five business days following the reporting date to ensure the accuracy of the information. As an additional layer, the Financial Aid Manager will also calendar a review reminder. Permanent address changes will be reported on a six-week cycle after the add/drop period each term. Address changes will also be sample reviewed to ensure accuracy within NSLDS.

View Audit 290324

Finding 367196 (2023-002)

Significant Deficiency 2023

Hamline University of Minnesota

MN

Student Financial Aid Reporting Significant Deficiency

Department of Education 2023-002 Student Financial Assistance – 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 student status changes are b...

Department of Education 2023-002 Student Financial Assistance – 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 student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: Auditors identified five students where the change in enrollment status was not reported in a timely manner. It was noted that we identified the status changes while there was a cybersecurity breach within the file transfer system used by the National Student Clearinghouse (NSC), our third-party servicer. As a result, our reporting was delayed. We received notice of the incident from the NSC on June 16, 2023. Our next planned transmission was scheduled for June 28. We postponed our regular reporting schedule for one week while we reset our secure FTP password with NSC, initialized our account in their updated system, and while our ITS security officer evaluated the risk. We ended up submitting the file to the NSC on July 5. As a result of this incident, we remain vigilant for external factors that may impact our reporting schedule. We will address them as quickly as possible to avoid reporting delays. Names of the contact persons responsible for corrective action: Gwenn Sherburne, Registrar Planned completion date for corrective action plan: By first reporting date for 2023-2024 academic year in early September 2023.

View Audit 290314

Finding 367192 (2023-001)

Significant Deficiency 2023

University of Saint Katherine

CA

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: USK's 001 Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1. Write a comprehensive Information Security Program, specifically addressing GLBA compliance, and the below areas of concern: a. Design and impleme...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: USK's 001 Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1. Write a comprehensive Information Security Program, specifically addressing GLBA compliance, and the below areas of concern: a. Design and implement safeguards to protect customer information. b. Address risk assessment, identifying how risks are evaluated and categorized and how existing controls mitigate these risks. Include a plan to implement additional mitigations or formal risk acceptance for any risks outside of management’s risk. c. Detail and establish continuous monitoring processes for information systems or periodic vulnerability assessments and penetration testing. d. Implement policies and procedures that support employee and information security staff training, awareness, and skills. e. Create procedures to periodically assess service providers. f. Review the plan annually, or as needed, as policies, vendors, and staffing change g. Present the written annual status report on the effectiveness of the program to USK’s cabinet Persons Responsible for Corrective Action Plan: Laurel Maguire Controller, Director of HR / Marina Trigonis COO / Wayne Mealhouse - LinkServ Anticipated Date of Completion: May 1st, 2024

View Audit 290312

Finding 367079 (2023-001)

Significant Deficiency 2023

Avondale Elementary School District No. 44

AZ

Questioned Costs Cash Management Reporting

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.559 Contact Person: Vanessa Bonfim Anticipated Completion Date: March 6, 2024 Planned Corrective Action: • In order to ensure that correct claim numbers are ...

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.559 Contact Person: Vanessa Bonfim Anticipated Completion Date: March 6, 2024 Planned Corrective Action: • In order to ensure that correct claim numbers are submitted to AZ Department of Education, the Food Services Department will perform double monthly checks when claims are entered into ADEConnect website, before actual submission. • Claims are entered into ADEConnect by the Food Service Liaison and double check will occur at the same time by the food service supervisor. • Monthly scheduled time will be set once a month to process claims.

View Audit 290291 Questioned Costs: $1

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