Corrective Action Plans

Finding 12466 (2022-001)

Significant Deficiency 2022

PA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC t...

2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC timely. Context: The PRAC expired March 31, 2022, and was not renewed until August 29, 2022. Recommendation: The Corporation should ensure the PRAC is renewed on a timely basis annually. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for timely submissions of proposed budgets and contract completion. A master schedule has been set up and all budget submissions will now be reviewed by the Finance Department prior to submission. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 16911

Finding 12459 (2022-005)

Significant Deficiency 2022

Maysville R-1 School District

MO

Reporting Significant Deficiency

2022-005 Reconciliation of SEFA to Underlying Financial Statements - The District corrected the totals for the 2021-2022 SEFA, and will carefully review the coding of Federal expenditures going forward.

View Audit 16893

Finding 12458 (2022-004)

Significant Deficiency 2022

Maysville R-1 School District

MO

Reporting Significant Deficiency

2022-004 Missing Assistance Listing Numbers - The District has corrected the SEFA totals for 2021-2022 to include the assistance listing numbers previously not included, and will include them going forward.

View Audit 16893

Finding 12457 (2022-003)

Significant Deficiency 2022

Maysville R-1 School District

MO

Reporting Subrecipient Monitoring Significant Deficiency

2022-003 Identification of Pass-through Entities - The District has corrected the SEFA totals for 2021-2022 to include the pass-through entities previously not included, and will correct its review process going forward.

View Audit 16893

Finding 12450 (2022-001)

Significant Deficiency 2022

Benson Unified School District No. 9

AZ

Significant Deficiency Special Tests & Provisions

Finding Number: 2022-001 Program Name/Assistance Listing Title: COVID-19 Education Stabilization Fund Assistance Listing Numbers: 84.425U Contact Person: Connie Ayres, Business & HR Director Anticipated Completion Date: February 28, 2023 Planned Corrective Action: The District will review all federa...

Finding Number: 2022-001 Program Name/Assistance Listing Title: COVID-19 Education Stabilization Fund Assistance Listing Numbers: 84.425U Contact Person: Connie Ayres, Business & HR Director Anticipated Completion Date: February 28, 2023 Planned Corrective Action: The District will review all federally-funded projects and determine which are subject to prevailing wage rate requirements. The District when applicable, will obtain certified payrolls from contractors and subcontractors to determine that prevailing wage rate requirements are met.

View Audit 16884

Finding 12433 (2022-001)

Significant Deficiency 2022

Geneva Avenue Elderly Housing, Inc. 023-Ee-110

MA

HUD Housing Programs Subrecipient Monitoring Eligibility § 200.516

Project Legal Name: Geneva Avenue Elderly Housing, Inc. HUD Project No.: 023-EE-110 Audit Firm: Cohnreznick LLP Period covered by the audit: 7/1/2021 ? 6/30/2022 Corrective Action Plan prepared by: Name: Amy Lawton Position: Regional Manager Telephone Number: 617-209-5266 The following is...

Project Legal Name: Geneva Avenue Elderly Housing, Inc. HUD Project No.: 023-EE-110 Audit Firm: Cohnreznick LLP Period covered by the audit: 7/1/2021 ? 6/30/2022 Corrective Action Plan prepared by: Name: Amy Lawton Position: Regional Manager Telephone Number: 617-209-5266 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation Management agrees with the finding and the recommendation in the finding. b. Action(s) Taken or Planned on the Finding In order to verify that all EIV reports are being run in accordance with HUD regulations, an internal audit will be performed on a routine basis. This audit will be conducted by a Senior Manager, a Regional Manager, or by a member of the Compliance Department. This internal audit will be performed at the end of each fiscal quarter. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations N/A

View Audit 16853

Finding 12425 (2022-003)

Significant Deficiency 2022

Town of Taylortown

NC

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

Finding 2022-003 Name of Contact Person: Rita Maness, Town Clerk Corrective Action: Management will assess short lived asset needs and establish a short lived asset reserve fund. Anticipated Completion Date: Management will implement the above procedures immediately.

View Audit 16821

Finding 12410 (2022-003)

Significant Deficiency 2022

Center City Housing Corp.

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Name of contact person: Kris Meyer, Director of Operations Corrective Action: Management of the Corporation hired additional staff to allow management the additional time necessary to prepare and review internal financial statements in a timely and efficient manner so that the audit can begin and be...

Name of contact person: Kris Meyer, Director of Operations Corrective Action: Management of the Corporation hired additional staff to allow management the additional time necessary to prepare and review internal financial statements in a timely and efficient manner so that the audit can begin and be completed in a timely and efficient manner. A separate issue arose during the 2022 audit which will cause a repeat finding in the 2023 audit, but Management believes their processes are properly designed to ensure timely filing of the Single Audit Reporting Package under normal circumstances. Proposed completion date: The Organization plans to complete the plan by September 30, 2023.

View Audit 18183

Finding 12406 (2022-001)

Significant Deficiency 2022

Planned Parenthood of Greater Texas, Inc.

TX

Allowable Costs / Cost Principles Eligibility Significant Deficiency

2022-001 Finding: Missing eligibility forms for Title X Patients Planned Parenthood of Greater Texas (PPGT) was awarded a five-year Title X grant in March 2022. At that time, it was necessary to write new policies, develop forms, trainings, and provide staff education on Title X expectations. The 20...

2022-001 Finding: Missing eligibility forms for Title X Patients Planned Parenthood of Greater Texas (PPGT) was awarded a five-year Title X grant in March 2022. At that time, it was necessary to write new policies, develop forms, trainings, and provide staff education on Title X expectations. The 2023 financial audit was the first audit of Title X since PPGT regained the program a year earlier. The audit identified gaps in understanding of front-line staff and PPGT policy. Corrective Action Plan Annual Title X training will be provided to staff Title X centers in mid-June 2023. The training will include expanded direction and provide clarity for the staff regarding the expectations around eligibility forms. In April 2023, the Sr. Grants Project Manager began performing monthly chart audits across all Title X sites to assess compliance with the 340b program. The audits review ten charts from each Title X center, chosen at random. The criteria include looking for evidence demonstrating compliance with the requirement that an eligibility Form is completed with income information and signed by the patient. Following an audit, a report is provided to the 340b committee and further corrective action will be taken as needed.

View Audit 18182

Finding 12384 (2022-001)

Significant Deficiency 2022

Dominican University of California

CA

Student Financial Aid Allowable Costs / Cost Principles Cash Management

3/30/2023 Grant Thornton 10 Almaden Blvd., Suite 800 San Jose, CA 95113 RE: Management?s Corrective Action Plan in Response to Fiscal Year 2022 Item 2022-001 ? Significant Deficiency ? Reporting: Special Reporting 1. Contact person: Syble Allen, Controller 2. Plan of action: The Controller, D...

3/30/2023 Grant Thornton 10 Almaden Blvd., Suite 800 San Jose, CA 95113 RE: Management?s Corrective Action Plan in Response to Fiscal Year 2022 Item 2022-001 ? Significant Deficiency ? Reporting: Special Reporting 1. Contact person: Syble Allen, Controller 2. Plan of action: The Controller, Director of Institutional Research and Student Accounts Director will all be given copies of the prepared FISAP for review and comment at least 3 days prior to FISAP submission each October 1. 3. Anticipated completion date: This new process will be implemented April 1, 2023.

View Audit 16199

Finding 12323 (2022-001)

None 2022

Western Maine Community Action, Inc.

ME

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Corrective Action Plan for Current Year Findings 2022-001 ? Data Collection Form Late Filing Corrective Action Plan To ensure proper timing of the Data Collection Form filing, the CFO will certify and file the data collection form for FY2022 with the Federal Audit Clearinghouse on May 31, 2023, afte...

Corrective Action Plan for Current Year Findings 2022-001 ? Data Collection Form Late Filing Corrective Action Plan To ensure proper timing of the Data Collection Form filing, the CFO will certify and file the data collection form for FY2022 with the Federal Audit Clearinghouse on May 31, 2023, after receiving notification from the auditors that it is ready. The CFO will send a confirmation email to the auditing firm, as well as the CEO upon filing. WMCA will ensure the Accounting Policies and Procedures for WMCA reflect that we must submit within 30 days after receipt of the auditor?s report or nine months after the end of their audit period ? whichever comes first, as required by Federal law. Person(s) Responsible: Rebecca Gage, CFO Timing for Implementation: Implement immediately. Submit within the same day of auditors notice for FY2023. Check and revise policy and procedures, if necessary, within 90 days.

View Audit 16716

Finding 12318 (2022-001)

Significant Deficiency 2022

Ucc Iii, Inc. D/b/a Oakhaven Community

OH

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

"""Condition: HUD guidelines regarding the EIV system were not followed and the EIV system reports were not utilized timely during 2022. Planned Corrective Action: Management has implemented guidelines and trainings surrounding the use of the EIV system. Management will continue to monitor the appro...

"""Condition: HUD guidelines regarding the EIV system were not followed and the EIV system reports were not utilized timely during 2022. Planned Corrective Action: Management has implemented guidelines and trainings surrounding the use of the EIV system. Management will continue to monitor the appropriate use of the EIV system. Contact person responsible for corrective action: Julie Reed, Housing Accounting Manager Anticipated Completion Date: December 31, 2023 "" "

View Audit 16679

Finding 12261 (2022-003)

Significant Deficiency 2022

Adams County Housing Authority

PA

HUD Housing Programs Allowable Costs / Cost Principles Significant Deficiency

Recommendation We recommend that the Authority implement additional review procedures over invoices to verify the allocation according to the cost allocation plan. View of responsible officials and planned corrective action We agree that there were some expenses that did not follow the cost allocat...

Recommendation We recommend that the Authority implement additional review procedures over invoices to verify the allocation according to the cost allocation plan. View of responsible officials and planned corrective action We agree that there were some expenses that did not follow the cost allocation and that in all cases noted, we undercharged the HCV program. We will implement further review processes that reference expenses directly back to the cost allocation plan.

View Audit 16514

Finding 12260 (2022-002)

Significant Deficiency 2022

Adams County Housing Authority

PA

HUD Housing Programs Reporting Significant Deficiency

Recommendation We recommend that the Authority implement additional review procedures over the HAP contract and documentation prior or soon after the file is finalized. View of responsible officials and planned corrective action We agree that this compliance requirement is listed in the compliance ...

Recommendation We recommend that the Authority implement additional review procedures over the HAP contract and documentation prior or soon after the file is finalized. View of responsible officials and planned corrective action We agree that this compliance requirement is listed in the compliance supplement. We will implement additional review procedures to capture any missing or errors in the reporting. Additional training has been provided to the HCV Staff.

View Audit 16514

Finding 12259 (2022-001)

Significant Deficiency 2022

Adams County Housing Authority

PA

HUD Housing Programs Significant Deficiency

Recommendation We recommend that the Authority to investigate the use of form and verify its existence or the need to file a new form. View of responsible officials and planned corrective action We agree that this compliance requirement is listed in the compliance supplement and due to the age of t...

Recommendation We recommend that the Authority to investigate the use of form and verify its existence or the need to file a new form. View of responsible officials and planned corrective action We agree that this compliance requirement is listed in the compliance supplement and due to the age of the bank account the form was not able to be located during the duration of the audit. HUD Form 51999 will be updated and submitted to HUD for approval.

View Audit 16514

Finding 12245 (2022-001)

Significant Deficiency 2022

Brigham Young University - Hawaii

HI

Student Financial Aid Reporting Eligibility

BRIGHAM YOUNG UNIVERSITY-HAWAII Management's View and Corrective Action Plan Finding 2022-001- Non-Compliance with Timely and Accurate Student Enrollment Change Submissions to the National student Loan Data System (significant Deficiency) Grantor: U.S. Department of Education Program : Student Finan...

BRIGHAM YOUNG UNIVERSITY-HAWAII Management's View and Corrective Action Plan Finding 2022-001- Non-Compliance with Timely and Accurate Student Enrollment Change Submissions to the National student Loan Data System (significant Deficiency) Grantor: U.S. Department of Education Program : Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant program Award Years: 7/2021 - 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan Corrective Action Plan: Due to the NSLDS outage as announced by the U.S. Department of Education Federal Student Aid's (FSA) office, we were unable to submit enrollment rosters for the period of July 19,2022 through February 28, 2023. Therefore, we are continuing to implement the following corrective action plan to address both the prior year and current year issues as discussed below. The current year finding is the result of three separate reporting issues. The first issue is a repeat finding from the 2021 fiscal year audit (2021-001) related to inaccurately reporting the status of graduated students. When graduation files were sent to the National Student Clearinghouse (NSC), many could not be processed due to the "G" status not being applied when students were reported as graduated. Because of this, the NSC was not sending graduation information for some students to the National Student Loan Data System (NSLDS). Therefore, to appropriately resolve this issue, Daryl Whitford, Registrar, will regularly access the NSC dashboard, prior to submitting of monthly enrollment report, to promptly identify and resolve any reporting issues to ensure NSLDS has the correct information for students. The second issue is a repeat finding from the 2021 fiscal year audit (2021-001) and is the result of inappropriate configuration of each semester's credit load determinations (i.e., how many credits constitute full time, three quarter time, half time, etc.) into PeopleSoft. As a result of the inappropriate configuration, certain student statuses were reported incorrectly given the number of credit hours the student was attending. To ensure accuracy of each semester's credit load determinations, at the beginning of each semester, Daryl Whitford, Registrar, will review and approve the credit load determinations prior to them being pushed into PeopleSoft. This will ensure that PeopleSoft is configured to communicate the appropriate statuses to the NSLDS. The third issue referenced the reporting of the correct program begin dates. When a student returns from a leave of absence or an internship, PeopleSoft updates the students program begin date for the students return date rather than the original program begin date. Daryl Whitford, Registrar, will perform a review of program begin dates for students returning from a leave of absence to ensure the proper program begin date is reported. In addition, we will review if any PeopleSoft enhancements can be made to provide additional comfort that the program begin dates are accurate in these circumstances. Daryl Whitford, Registrar, who is responsible for enrollment reporting at Brigham Young University- Hawaii will continue to provide training to staff who participate in enrollment reporting to ensure that they are aware of the campus and program enrollment changes to be reported, the details to be reported for each change, and the importance of submitting changes timely. Also, Daryl Whitford, Registrar, will oversee the implementation of a control wherein the University will sample students from each roster submission and trace the information from the batch file back to the supporting documentation to ensure that the information included in the batch roster file is accurate. Timing: Daryl Whitford, Registrar, will be responsible to oversee that the items as noted in the Corrective Action Plan section above will be implemented by July 1, 2023. Signed and Acknowledged Daryl Whitford Registrar

View Audit 16491

Finding 12242 (2022-004)

Significant Deficiency 2022

Pioneer Housing Development Inc. Dba John Paul Apartments 092-11212

MN

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2022-004 Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance U.S. Department of Housing and Urban Development CFA #14.134 Section 207 Insured Loan Balance Finding Summary: Upon termination of lease, Minnesota statutes require that th...

Finding 2022-004 Special Tests and Provisions Noncompliance and Significant Deficiency in Internal Control over Compliance U.S. Department of Housing and Urban Development CFA #14.134 Section 207 Insured Loan Balance Finding Summary: Upon termination of lease, Minnesota statutes require that the Project refund tenant security deposits within 21 days of termination of tenancy. The Project did not pay out one deposit within the 21 day requirement for termination of tenancy. Responsible Individuals: Brenda Weller, Director of Finance Corrective Action Plan: Management agrees with the finding and will work to refund tenant security deposits within 21 days of termination of tenancy. Anticipated Completion Date: December 31, 2023

View Audit 16461

Finding 12229 (2022-004)

Significant Deficiency 2022

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-004 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will re...

Finding Number: 2022-004 Finding Title: Child Support Non-Cooperation Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

View Audit 16416

Finding 12228 (2022-003)

Significant Deficiency 2022

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-003 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant poli...

Finding Number: 2022-003 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Jeremy Allen Corrective Action Planned: Agency will correct the cases that were cited for errors. Supervisor will review relevant policies for assets and child support non-coop with Eligibility workers on the Family Team to provide additional support and guidance for processing of these cases. Anticipated Completion Date: 8/31/2023

View Audit 16416

Finding 12226 (2022-001)

Significant Deficiency 2022

Minnesota Prairie County Alliance

MN

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment Significant Deficiency

Finding Number: 2022-001 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Kevin Venenga Corrective Action Planned: A review of our current policy is under...

Finding Number: 2022-001 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Kevin Venenga Corrective Action Planned: A review of our current policy is underway, and it will be updated appropriately to meet all federal requirements. Anticipated Completion Date: 12/31/2023

View Audit 16416

Finding 12221 (2022-001)

Significant Deficiency 2022

The Housing Authority of the City of Decatur, Alabama

AL

Special Tests & Provisions Reporting Significant Deficiency

February 10, 2023 Rubino & Company 6903 Rockledge Drive, Suite 1200 Bethesda, MD 20817-1818 Re: Corrective Action Plan to Finding 2022-001 Housing Authority of the City Decatur received the draft audit report for Fiscal Year Ended June 30, 2022. As per your request, this is the Corrective Action Pla...

February 10, 2023 Rubino & Company 6903 Rockledge Drive, Suite 1200 Bethesda, MD 20817-1818 Re: Corrective Action Plan to Finding 2022-001 Housing Authority of the City Decatur received the draft audit report for Fiscal Year Ended June 30, 2022. As per your request, this is the Corrective Action Plan for the finding in Section III ? Federal Award Findings and Questioned Costs. Finding 2022-001 Public and Indian Housing ? Special Test and Provisions ? Wage Rate Requirements Significant Deficiency in Internal Controls Cause: The Authority failed to obtain payroll reports for one of the contracts that required Davis-Bacon wage requirements. Auditor?s Recommendation: We recommend that DHA obtain and review the missing payroll reports from the contractor, and if necessary, follow up on any non-compliance. DHA should also establish procedures to ensure that required payroll reports are obtained for all contracts subject to Davis-Bacon wage requirements. DHA Corrective Action Plan: DHA failed to obtain payroll reports from said contractor. Moving forward Taura L. Denmon, Executive Director or Mechelle Dowdy, Director of Housing will be responsible for receiving and checking Davis-Bacon wage reporting requirements. Staff Contact: Taura L. Denmon, Executive Director Target Completion Date: October 31, 2022 Sincerely, Taura L. Denmon Executive Director

View Audit 16376

Finding 12216 (2022-001)

Significant Deficiency 2022

Duncanville Independent School District

TX

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

Corrective Action Plan Finding 2022-001 Assistance Listing # 84.010A Title I, Part A Department of Education passed through Texas Education Agency Compliance Requirements: Special Tests and Provisions - Annual Report Card, High School Graduation Rate Significant Deficiency in Controls over Complianc...

Corrective Action Plan Finding 2022-001 Assistance Listing # 84.010A Title I, Part A Department of Education passed through Texas Education Agency Compliance Requirements: Special Tests and Provisions - Annual Report Card, High School Graduation Rate Significant Deficiency in Controls over Compliance Views of Responsible Officials and Planned Corrective Actions: While Duncanville High School works diligently to make sure that all students leaving the district are correctly documented, we will take the following measures to insure that 100% of leaver records are complete and accurate: 1. DHS will immediately begin cross training office personnel so that multiple personnel will be able to correctly withdraw all students, 2. DHS will put into place a fail-safe system where all withdrawal documents are double checked and signed off by an administrator, and 3. The PEIMS department will check all records for accuracy and completion for all students withdrawing. These steps will insure that Duncanville High School will be 100% complaint with all withdrawal of students. Person responsible: Duncanville High School: Executive Principal PEIMS: Director of Informational lSystems

View Audit 16362

Finding 12195 (2022-002)

Significant Deficiency 2022

Ensign College

UT

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

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023...

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan This issue is a result of no manual or system controls in place to prevent disbursement of financial aid to a student?s account if a student?s federal financial aid award notification was not yet communicated. This issue was corrected as soon as it was identified by changing our procedures to require Pell notification letters be sent as soon as funds are awarded and before funds are disbursed to a student?s account. As an additional precaution, Pell notification letters will be added to the nightly batch process in PeopleSoft to ensure letters are sent timely. Financial aid staff will also receive additional training in this area. Timing Procedures will be changed in May 2023 by Riley Niemand, Manager of Financial Aid, to require Pell notification letters be sent as soon as funds are awarded and prior to funds being disbursed to a student?s account. During May 2023, Riley Niemand will also provide additional training to financial aid staff in this area. Additionally, Riley Niemand started working with a consultant to add Pell notification letters to the daily batch process. This work is expected to be complete by June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

View Audit 16301

Finding 12194 (2022-001)

Significant Deficiency 2022

Ensign College

UT

Student Financial Aid Eligibility Significant Deficiency

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Pr...

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan The prior year corrective action plans were successful in addressing the issues identified in previous audits in enrollment reporting. These additional steps will be taken to address the new issues found during the 2022 audit within enrollment reporting, which resulted in a repeat finding of 2021-001. Grayson Layton, Registrar, will review the College?s policies and procedures surrounding student enrollment and enrollment reporting, starting in May 2023 specifically as it relates to students that have withdrawn that are expected to return in the subsequent semester but fail to reenroll. Any changes in the College?s policies and procedures will be appropriately documented and communicated to the individuals involved in updating student enrollment information in the system. Additionally, Enrollment Services will work with a PeopleSoft consultant and technical staff to customize our Student Information System to allow for the correct reporting of student status to the National Student Clearinghouse (NSC). Technical staff and a consultant will be engaged to perform an evaluation of all systems and practices related to enrollment reporting. The Enrollment Services and Financial Aid and Scholarships Offices will use various NSC and National Student Loan Data System (NSLDS) error reports to ensure student enrollment information, including program level information, is reported in an accurate and timely manner. Timing Grayson Layton, Registrar, will work with consultants and technical staff starting in May 2023 to begin making necessary adjustments to the Student Information System to allow for accurate reporting of student enrollment information and to evaluate systems and practices related to enrollment reporting. They will meet monthly throughout the year to monitor their progress with an expected completion in December 2023. Grayson and Riley Niemand, Manager of Financial Aid, will coordinate the use of NSC and NSLDS error reports to identify students with reporting errors. This process will be complete in June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

View Audit 16301

Finding 12166 (2022-001)

Significant Deficiency 2022

Marana Health Center, INC

AZ

Significant Deficiency Internal Control / Segregation of Duties

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. ...

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. PURPOSE: The Sliding Fee Schedule (SFS) Patient Demographic Changes process was created to ensure any patient who is certified on MHC Healthcare's (MHC) SFS and has changes on their Patient Profile (Profile) to their Family Size and/or Income are referred to the Outreach Department (OR) and that these changes are only made by an OR employee or the OR Manager. II. PROCESSES: A. Front Office (FO) staff print Profiles from the Electronic Health Record (EHR) for all patient appointments, which allows patients to make required changes to their demographics on file. This includes Family Size and/or Income. When a patient on MHC's SFS notifies FO of changes to the aforementioned demographics, the patient must be referred to the MHC OR Department for further review. Only OR staff may make these demographic changes in the EHR for SFS Patients. Ill. PROCEDURES: A. FO staff will print a Profile for all patient appointments. 1. FO will ensure all patients review the Profile for required changes to their demographics in the EHR system. a. If the patient is on the SFS and notates any changes required on the Profile to be made to their Family Size and/or Income, the FO will: 1) Immediately notify the health center's assigned OR employee that a patient in the office for an appointment has required changes to these demographics. a) Notification can be made via telephone or a Teams message. b) If the site does not have an assigned OR employee, notification will be made to the OR Manager. 2) The OR employee will respond to FO: a) The patient is placed on the OR schedule for an immediate appointment while the patient is in the health center and available, either prior to or after the clinical visit, depending on allowable time. b) An appointment will be scheduled while the patient is in the health center for a later date to review changes and the possible affect these changes may have on the patient's SFS certification and/or SFS tier. c) The patient is contacted via telephone by the OR employee to schedule an appointment to review the possible changes to the patient's SFS certification and/or SFS tier. d) When scheduling the appointment, the patient may schedule it at the Health Center or choose to have this appointment via telehealth. 3) Only OR employees may change the Family Size and/or Income demographics in the EHR for SFS patients. a) FO will make all necessary demographic changes in the EHR, excluding Family Size and/or Income. b. FO will scan the Profile into the EHR and forward a copy to the appropriate OR employee. 2. The OR Manager will ensure that FO staff have a current list of OR employees, along with appropriate contact information and location. Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 2 of 2 3. The OR Manager will immediately communicate any deviations to this policy and procedure to the assigned Associate Director of Integrated Operations (ADIO) when noted. IV. REFERENCES: Sliding Fee Schedule V. ATTACHMENTS: None Approved: Original Approval: 09/2022 9/28/2022 Date 9/28/2022 Date Reviewed/Revised: Responsible Party: Director, Integrated Operations If the Department of Health and Human Services has questions regarding this plan, please call Tamie Olson, CFO at (520) 784-8655.

View Audit 16269

Corrective Action Plans

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