Corrective Action Plans

Finding 9570 (2023-002)

Significant Deficiency 2023

OR

HUD Housing Programs Eligibility Significant Deficiency

2023-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement wi...

2023-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: NOHA has reviewed its policies regarding documentation maintenance for all individuals on the waiting list. Quality control review of waiting list data entry was put in place after October 2020. The oldest application on the current HCV waiting list is dated 2019. NOHA anticipates this finding may continue until the waiting list application dates reach 10/2020. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2024

View Audit 13226

Finding 9568 (2023-001)

Significant Deficiency 2023

Northwest Oregon Housing Authority

OR

Questioned Costs HUD Housing Programs Eligibility

2023-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: T...

2023-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Northwest Oregon Housing Authority has reviewed eligibility determination and documentation processes. Staff have received updated training regarding proper data entry of assets and application of COLA. NOHA continues to conduct on-going quality control file reviews to monitor file quality; year to date, approximately 6.5% of transactions have been reviewed. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2024

View Audit 13226 Questioned Costs: $1

Finding 9474 (2023-002)

Significant Deficiency 2023

Bevill State Community College

AL

Special Tests & Provisions Student Financial Aid Significant Deficiency

Corrective Action Plan: Management is in the process of updating Policies and Procedures to help ensure that calculations are run correctly and timely. The Financial Aid office and the Finance Office will work together each semester to ensure Banner setup is correct, updated, and working properly pr...

Corrective Action Plan: Management is in the process of updating Policies and Procedures to help ensure that calculations are run correctly and timely. The Financial Aid office and the Finance Office will work together each semester to ensure Banner setup is correct, updated, and working properly prior to any calculations being performed. Anticipated Completion Date: January 31, 2024

View Audit 12991

Finding 9460 (2023-001)

Significant Deficiency 2023

Warner University, Inc.

CO

Subrecipient Monitoring Significant Deficiency

Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting th...

Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting the decreased mitigated risk level. We have a legacy on premise legacy SIS application software that doesn't have the capacity for MFA. We will attempt to either move our on-premise application software and database to our vendor's location where MFA is required to get into their network, or we will source a third-party vendor that will work with a legacy application without MFA capacity and require MFA on the front-end before calling the application. We will also consider application software on University-owned computer workstations and laptops that require MFA upon logging into our campus network. We will source an outside company for penetration testing and vulnerability scanning. Then, review the results and put in a plan to address the critical items and track progress. We will document each vendor that hosts PII data. We will collect SOC reports, privacy statements, GLBA compliance documents, and other related documents. We will provide the Board of Trustees - Business/Finance Committee a written report on the current status of the Information Security Program document. Person Responsible for Corrective Action Plan: Kelvin D Tohme, Senior Director of Information Technology Anticipated Date of Completion: Spring 2024

View Audit 12966

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Outside In will update our Procurement Policy to verify status of suspension or debarment for all potential contractors being considered for use of federal funds. The verification process will include one or more of the following verification methods to demonstrate compliance with federal regulation...

Outside In will update our Procurement Policy to verify status of suspension or debarment for all potential contractors being considered for use of federal funds. The verification process will include one or more of the following verification methods to demonstrate compliance with federal regulations before purchase of goods, contract for services (including purchase orders) or subaward funds.

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

1

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Obtain a signed certificate from the contractor attesting it is not suspended or debarred.

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

2

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Insert a clause into the contract stating the contractor is not suspended or debarred.

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

a.

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Note: If you go this route, including a suspension and debarment clause in your request for proposal is insufficient. The clause must be part of the contract. Its possible language included on a purchase order would work, but you should check with your grantor first to determine if this would be acc...

Note: If you go this route, including a suspension and debarment clause in your request for proposal is insufficient. The clause must be part of the contract. Its possible language included on a purchase order would work, but you should check with your grantor first to determine if this would be acceptable. If so, the contractor must sign the purchase order.

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

3

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Check the contractor's status on the U.S. General Administration's website before contracting or purchasing. Type your contractor's name into the search bar to find exclusion records.

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Note: Be sure you keep documentation that demonstrates you performed the search, including the date. For example, you might save a screen shot that includes the date you performed the search.

View Audit 12942

Finding 9454 (2023-002)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

All front desk staff will complete comprehensive training on applying the Sliding Fee Discount Policy to patient fees. Supervisors will conduct a competency check with each staff member and retain a signed competency form on the Sliding Fee Discount Schedule (SFDS) policy in their personnel file. Th...

All front desk staff will complete comprehensive training on applying the Sliding Fee Discount Policy to patient fees. Supervisors will conduct a competency check with each staff member and retain a signed competency form on the Sliding Fee Discount Schedule (SFDS) policy in their personnel file. This will be complete by the end of January 2024 and incorporated into onboarding and orientation for new hires moving forward (to be completed within two weeks of the start date).

View Audit 12942

Finding 9454 (2023-002)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Front desk supervisors at all clinic sites will be responsible for doing a weekly audit of fee collection amounts to ensure that visit fees are being collected appropriately according to the Sliding Fee Discount Policy. We will work to re-institute a regular copay report which will improve the flow ...

Front desk supervisors at all clinic sites will be responsible for doing a weekly audit of fee collection amounts to ensure that visit fees are being collected appropriately according to the Sliding Fee Discount Policy. We will work to re-institute a regular copay report which will improve the flow of information between the front desk, IT / data, and the fiscal teams, allowing for more timely

View Audit 12942

Finding 9401 (2023-002)

Significant Deficiency 2023

D H, Incorporated

OR

HUD Housing Programs Reporting Significant Deficiency

Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be s...

Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be submitted to HUD within 90 days of the fiscal year end. HUD may authorize an extension to the 90 day due date. Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 3. The anticipated completion date: a. New property accountant was hired in August of 2023.

View Audit 12871

Finding 9373 (2023-005)

Significant Deficiency 2023

Somerset Academy of Las Vegas

NV

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the ...

Finding Number: 2023-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 12842

Finding 9363 (2023-004)

Significant Deficiency 2023

Sports Leadership and Management Academy of Nevada

NV

Allowable Costs / Cost Principles School Nutrition Programs Significant Deficiency § 200.303

Finding Number: 2023-004 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 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 grant...

Finding Number: 2023-004 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 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, 2024

View Audit 12841

Finding 9341 (2023-003)

Significant Deficiency 2023

Sports Leadership and Management Academy of Nevada

NV

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-003 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the ...

Finding Number: 2023-003 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 12841

Finding 9337 (2023-002)

Significant Deficiency 2023

Paris Junior College

TX

Student Financial Aid Cash Management Reporting

Corrective Action Plan (Continued) Year Ended August 31, 2023 2023-02 Recommendations: Paris Junior College's management should implement additional controls and procedures to ensure compliance requirements are met regarding the posting of contracted arrangements with financial account providers to ...

Corrective Action Plan (Continued) Year Ended August 31, 2023 2023-02 Recommendations: Paris Junior College's management should implement additional controls and procedures to ensure compliance requirements are met regarding the posting of contracted arrangements with financial account providers to the Department of Education's database. Additionally, the College must establish a procedure to accomplish a due diligence review of the financial account provider's rates and fees. Action Plan: Paris Junior College management will ensure that a comprehensive procedure is established and implemented to ensure compliance requirements are met. Contact Person: Debra Craig, Controller Anticipated Completion Date: January 10, 2024

View Audit 12826

Finding 9314 (2023-003)

Significant Deficiency 2023

North Central Michigan College

MI

Student Financial Aid Eligibility Significant Deficiency

Auditor Description of Condition and Effect. Instead of earning additional aid due to the Return of Title IV calculation error, one of the twenty one students who were affected saw a reduction due to a transposition/rounding error that was missed in the original calculation. As a result of this cond...

Auditor Description of Condition and Effect. Instead of earning additional aid due to the Return of Title IV calculation error, one of the twenty one students who were affected saw a reduction due to a transposition/rounding error that was missed in the original calculation. As a result of this condition, input errors for the Return of Title IV calculations can make it through the process without being discovered. It is our understanding that on July 26, 2023, the College corrected the transposition/rounding error that impacted the students Return of Title IV calculation. Auditor Recommendation. Management has already taken appropriate corrective action by updating the returns for the student impacted by the input error. However, we recommend that the College implement a review process to ensure that the R2T4 calculation is being reviewed by a second individual. Corrective Action. The College has performed the necessary steps to correct the error and will amend the calculation process to ensure that a second individual is reviewing the work performed. Responsible Person. Katie Malone, Director of Student Aid Anticipated Completion Date. June 30, 2024

View Audit 12796

Finding 9308 (2023-002)

Significant Deficiency 2023

North Central Michigan College

MI

Special Tests & Provisions Significant Deficiency Equipment & Real Property Management

Auditor Description of Condition and Effect. The most recent Gramm Leach Bliley Policy fails to address the implementation of multi-factor authentication for anyone accessing customer information on the institution's system, conducting a periodic inventory of data that notes where it is collected, ...

Auditor Description of Condition and Effect. The most recent Gramm Leach Bliley Policy fails to address the implementation of multi-factor authentication for anyone accessing customer information on the institution's system, conducting a periodic inventory of data that notes where it is collected, store, or transmitted, encrypting customer information on the institution's system and when it's in transit, and the assessment of apps developed by the institution. As a result of this condition, the College isn't meeting the safeguard requirements necessary to comply with the FTC. In addition, the lack of safeguard controls creates an increased risk to highly sensitive data that is possessed by the College. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley Policies are met and verified by a second individual. Corrective Action. Currently, the College is reviewing the compliance requirements for Gramm Leach Bliley and will amend the current policy to ensure that each safeguard is being addressed within the policy. Responsible Person. Alex Freds, Director of IT Anticipated Completion Date. June 30, 2024

View Audit 12796

Finding 9302 (2023-001)

Significant Deficiency 2023

North Central Michigan College

MI

Student Financial Aid Eligibility Reporting

Auditor Description of Condition and Effect. For the Winter 2023 semester, a break of 5 days (excluding weekends) was being subtracted instead of 9 days (including weekends) from the total days in the term, which resulted in the calculation being incorrect for all students who had returns in the Win...

Auditor Description of Condition and Effect. For the Winter 2023 semester, a break of 5 days (excluding weekends) was being subtracted instead of 9 days (including weekends) from the total days in the term, which resulted in the calculation being incorrect for all students who had returns in the Winter 2023 semester. As a result of this condition, Return of Title IV calculations were incorrect for 21 students for the Winter 2023 semester, resulting in $4,265 in excess funds returned to the U.S. Department of Education. It is our understanding that on July 26, 2023, the College repaid the 21 students affected by this calculation error. Auditor Recommendation. Management has already taken appropriate corrective action by updating the returns for the 21 students impacted by the calculation error in the Winter 2023 Semester. However, we recommend that the College implement a review process to ensure that the R2T4 calculation is being reviewed by a second individual. Corrective Action. The College has performed the necessary steps to correct the error and will amend the calculation process to ensure that a second individual is reviewing the work performed. Responsible Person. Katie Malone, Director of Student Aid Anticipated Completion Date. June 30, 2024

View Audit 12796

Finding 9290 (2023-004)

Significant Deficiency 2023

Family First Health Corporation

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Planned Corrective Action: This was a repeat finding for Family First Health. Going forward future submissions will be reviewed for accuracy prior to submitting. Completion Date: 4/1/2024 Accounting Name of Contact Person: Jenny Englerth, President/CEO; Brent Doores, CFO

View Audit 12740

Corrective Action Plans

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