Corrective Action Plans

Finding 548753 (2024-003)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring HUD Housing Programs Reporting

2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharma...

2024-003. Incomplete Pharmacy Rebate Reporting and Invoicing State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Following the launch of the Medicaid Provider Reimbursement Information System for Medicaid (PRISM) in April 2023, not all pharmacy files from managed care entities and JCODE drugs properly transmitted to the third-party organization’s system. The key pharmacy claims files that needed to interface with the third-party organization’s system have now been rebuilt and are undergoing interface testing. After testing, the historic and more current files will be put into production and be transmitted to the third-party organization. Following receipt, the third-party organization will invoice and collect the unbilled rebates. Once this interface issue is resolved, all future required drug utilization data as well as rebate invoices will be sent to manufacturers within the required time frame. All claims received will be invoiced 60 days after the end of the current quarter they are received in, per CMS's rule. DHHS informed CMS of this issue in August 2024. At that time, CMS said the state was out of compliance and inquired on timelines to come into compliance. The state will provide updates to CMS when the backlogged files have been successfully transmitted and manufacturers have been invoiced. According to the third-party pharmacy organization, manufacturers were notified about this issue when it was discovered in May 2023 and advised that when the issues with invoicing these rebates is resolved they will be expected to pay the balance due. Implementation Date: May 30, 2025 Contact: Sepideh Daeery, Pharmacy Director, Division of Integrated Healthcare, sepidehdaeery@utah.gov Anticipated Correction Date: June 30, 2024

View Audit 352012

Finding 548751 (2024-011)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency

2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and p...

2024-011. DWS-Adopted Guidelines Not Followed When Evaluating an Applicant Housing Project State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

View Audit 352012

Finding 548749 (2024-010)

Significant Deficiency 2024

State of Utah

UT

Eligibility Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a r...

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

View Audit 352012

Finding 548698 (2024-015)

Significant Deficiency 2024

State of Utah

UT

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

2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative s...

2024-015. Reported Number of Homeowners Overstated State Agency: Department of Workforce Services Federal Agency: Department of the Treasury The Housing and Community Development Division will adopt a quality review process to address this finding. Fortunately, the Quarterly Reports are cumulative so we have updated the current report to reflect the accurate household counts with an AMI under 100%. Anticipated correction date: March 31, 2025 Responsible person: Ambra Peterson, HCD Program Manager, 385-312-6551

View Audit 352012

Finding 548697 (2024-014)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency

2024-014. Errors in Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has not received a response from the Treasury Office of Recovery Programs regarding the application of the $10 million capital expenditure re...

2024-014. Errors in Coronavirus SLFRF Quarterly Reports State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB has not received a response from the Treasury Office of Recovery Programs regarding the application of the $10 million capital expenditure reporting threshold. GOPB is working with the National Association of State Budget Officers to see if they can receive a response. GOPB will add a new capital expenditure section to each ARPA SLFRF Appropriation Tracking and Documentation Form to document the applicability of capital expense requirements for the project. If a project requires additional justification, based on clarification provided by the Treasury, GOPB and the agency will record the justification and documentation on the form and submit that information in the next quarterly ARPA SLFRF P&E Report-Quarter 4 2024. While preparing the October 2024 ARPA SLFRF P&E Report-Quarter 3 2024, GOPB will reconcile all reported obligations with backup documents. This reconciliation will be completed for future reports. Contact Person: Darcy Jaimez, Fiscal Grant Manager, 385-377-3373 Anticipated Correction Date: October 31, 2024

View Audit 352012

Finding 548696 (2024-013)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

2024-013. Misunderstanding Caused Improper Spending of Coronavirus State and Local Fiscal Recovery Funds (SLFRF) State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB agrees with the finding. We acknowledge that GOEO mistakenly recorded $559,900 of e...

2024-013. Misunderstanding Caused Improper Spending of Coronavirus State and Local Fiscal Recovery Funds (SLFRF) State Agency: Governor’s Office of Planning and Budget Federal Agency: Department of the Treasury GOPB agrees with the finding. We acknowledge that GOEO mistakenly recorded $559,900 of expenditures to the SLFRF program and identified the same error during the quarterly expenditure review process. Upon identifying this error, GOPB promptly addressed the issue with GOEO so that expenditures could be corrected in the financial system before the end of the FY 2024 closeout and the July 2024 quarterly ARPA SLFRF report. Corrective Action Plan: To improve oversight and monitoring of expenditures, GOPB will work closely with GOEO to ensure that all expenditures charged to SLFRF projects comply with program requirements. GOPB will also add content to agency SLFRF trainings about regularly reviewing project ARPA SLFRF Appropriation Tracking and Documentation Forms, which outline the budget, scope, eligibility, and coding for ARPA SLFRF projects. The training will specifically emphasize the importance of each agency establishing effective internal controls for recording and reviewing ARPA SLFRF expenditures. In addition to updating its general training materials, GOPB will provide additional training to agency staff managing new projects so they understand policies and procedures. Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592 Anticipated Correction Date: Completed October 31, 2024 State Agency: Governor’s Office of Economic Opportunity 1. GOEO will work with GOPB to ensure that all expenditures charged to SLFRF projects comply with program requirements. GOEO will participate in SLFRF trainings about regularly reviewing project ARPA SLFRF Appropriation Tracking and Documentation Forms, which outline the budget, scope, eligibility, and coding for ARPA SLFRF projects. Implementation of this plan has already begun and will be ongoing. 2. GOEO has improved internal controls. This includes improved review procedures by financial analysts and improved approval procedures by financial managers. Implementation of this plan is complete. Contact of Persons Responsible for Corrective Action: Kamron Dalton, Managing Director of Operations Jason Marden, Director of Finance Greg Jeffs, Agency Internal Audit Director (not responsible, but please cc communications)

View Audit 352012 Questioned Costs: $1

Finding 548694 (2024-009)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took ap...

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712

View Audit 352012 Questioned Costs: $1

Finding 548693 (2024-007)

Significant Deficiency 2024

State of Utah

UT

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applic...

2024-007. Refugee Grant Expenditures Charged Outside Award Period State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The department will implement a more detailed and thorough review of transactions to ensure that costs are attributed to the applicable period of performance in which the work was performed, and expenses were incurred and will ensure that costs are subsequently charged to the corresponding grant award. Anticipated correction date: January 31, 2025 Responsible person: Nathan Harrison, Executive Finance Director, 801-808-0676

View Audit 352012 Questioned Costs: $1

Finding 548692 (2024-006)

Significant Deficiency 2024

State of Utah

UT

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review...

2024-006. TANF ACF-204 Report Does Not Match Supporting Documentation State Agency: Department of Workforce Services Federal Agency: Department of Health and Human Services The report processes will be updated to add internal controls. The program manager will coordinate with finance staff to review all finance documentation utilized for the report. Prior to submission of the report, it will be reviewed by division and finance leadership to ensure the report aligns with documentation and is correct. Anticipated correction date: December 31, 2024 Responsible person: Liz Carver, Division Director, 801-514-1017

View Audit 352012

Finding 548660 (2024-002)

Significant Deficiency 2024

Food Lifeline

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and t...

Corrective Action: Management will track all grant expenditures using separate project codes for each award to ensure specific identification of the direct costs charged. Additionally, at the end of the reporting period, management will perform a reconciliation between the direct costs charged and the total revenues earned under each award to ensure the amounts are consistent with those reported in the schedule of expenditures of federal awards. Anticipated Completion Date: June 30, 2025

View Audit 351990

Finding 548655 (2024-004)

Significant Deficiency 2024

Ifoster, Inc.

CA

Reporting Significant Deficiency

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of California – California Volunteers Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: The OMB Compliance Supplement requires that reports submitted to the fed...

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of California – California Volunteers Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: The OMB Compliance Supplement requires that reports submitted to the federal awarding agency include all activity of the reporting period, are supported by underlying accounting information, and are presented in accordance with program requirements. Amounts reported on the SF-425 were not supported by the underlying accounting information. Responsible Individuals: Reid Cox, CFO Corrective Action Plan: Acknowledged. We have implemented a secondary review process of all SF-425 reports prior to submission. Anticipated Completion Date: Ongoing

View Audit 351989

Finding 548650 (2024-003)

Significant Deficiency 2024

Ifoster, Inc.

CA

Allowable Costs / Cost Principles Significant Deficiency § 200.430

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps St...

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: Title 2 U.S. Code of Federal Regulations (CFR) Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) section 200.430 provides that records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Amounts for certain personnel costs were not reimbursed at the correct pay rate for certain employees. Responsible Individuals: Reid Cox, CFO Corrective Action Plan: Acknowledged. While current year differences were immaterial and resulted in a slight underbilling, we have implemented a secondary review process of all calculations of hourly payrates to ensure consistency in the payrate calculation. Anticipated Completion Date: Ongoing

View Audit 351989

Finding 548621 (2024-001)

Significant Deficiency 2024

Northwest Arctic Borough, Alaska

AK

Reporting Procurement, Suspension & Debarment Significant Deficiency § 200.328

Name of Contact Person: Dickie Motto, Mayor and Jade Hill Treasurer Corrective Action Plan: NWAB established a policy/procedure to ensure that they are successful and compliant with the program’s reporting requirements and the award(s) are used in accordance with federal statutes, regulations, and ...

Name of Contact Person: Dickie Motto, Mayor and Jade Hill Treasurer Corrective Action Plan: NWAB established a policy/procedure to ensure that they are successful and compliant with the program’s reporting requirements and the award(s) are used in accordance with federal statutes, regulations, and the terms and conditions of the federal and state awards. Proposed Completion Date: Fiscal Year 2024

View Audit 351964

Finding 548619 (2024-003)

Significant Deficiency 2024

City of West Sacramento

CA

Subrecipient Monitoring Reporting Significant Deficiency

The Finance Department is currently implementing procedures to ensure all frequent and infrequent federal compliance requirements are thoroughly reviewed and adhered with for ongoing federal programs.

View Audit 351958

Finding 548605 (2024-002)

Significant Deficiency 2024

City of Madera

CA

Subrecipient Monitoring HUD Housing Programs Period of Performance

Finding 2024-002 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet ...

Finding 2024-002 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet criteria specified in the regulations that would exempt or exclude them from environmental certification requirements. For projects where the environmental review was not performed, a written documentation that the review was not required must be prepared. Condition and Context: The City could not provide support that there was pre-award or post-award review of grant projects to determine if a project requires an environmental review or is categorically excluded from the environmental review requirements. The City did not have adequate internal controls to ensure compliance with the special test – environmental review requirements. Testing was performed over each requirement for the City. Out of a total population of twelve (12) projects, we selected a sample of four (4) projects to test for environmental reviews. Four (4) out of the four (4) projects tested did not have an exemption report prepared in a timely manner. The sample was not intended to be, and was not, a statistically valid sample. City’s Corrective Action Plan: The City will reinforce its standard operating procedure concerning Environmental Reviews (ER) and will reinsure that environmental reviews are properly completed for every awarded grant project. Contact person responsible for corrective action: Michael Lima, Finance Director Anticipated completion date: June 30, 2025

View Audit 351953

Finding 548005 (2024-005)

None 2024

Quincy Asian Resources, Inc.

MA

Questioned Costs Significant Deficiency

Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that only actual hours spent working on the grant are charged to the grant as direct labor. The Organization is transit...

Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that only actual hours spent working on the grant are charged to the grant as direct labor. The Organization is transitioning to a new Time & Attendance system, which will address these issues.

View Audit 351904 Questioned Costs: $1

Finding 547968 (2024-002)

Significant Deficiency 2024

Nuestra Escuela

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2...

Management response: • Nuestra Escuela will design and implement internal controls specifically addressing the accounting of conditional advances. These controls will include developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. • The accounting staff will undergo specialized training on the proper recognition of conditional advances. Regular reviews will be conducted to ensure ongoing compliance with ASU 2018-08 and to maintain accurate financial reporting. • Recognizing the need to meet both agency (cash basis) and GAAP (accrual basis), Nuestra Escuela will prepare management reports on both bases. This approach will facilitate accurate grant reporting while ensuring compliance with generally accepted accounting principles. Corrective action plan: Action Date of Compliance Involved areas Developing a clear rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Apr 21 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Create a “Model reports” on both bases, to use monthly. Monthly Executive President Administrative Director Specialized training on the proper recognition of conditional advances. Jun 10 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Actions to complete monthly: • To prepare management reports on both bases Actions to complete quarterly: • Use the rubric to assess whether grants and contracts meet the criteria for conditional contributions under ASU 2018-08. Contact Person: Ana Yris Guzmán – Executive President

View Audit 351891

Finding 547967 (2024-001)

Significant Deficiency 2024

Nuestra Escuela

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to...

Management response: • Nuestra Escuela will strengthen its processes to ensure that all grants and accrued expenses are recorded promptly and that services rendered are accounted for in the correct period accurately. • The Administrative Director will perform regular reconciliations of accounts to detect, identify, and correct, any discrepancies that may indicate cut-off errors. • The administrative staff and accounting team will receive additional training on the best practices and proper cut-off procedures, emphasizing the importance of timely and accurate recognition of liabilities and receivables and the impact of errors on financial reporting. • Nuestra Escuela will reinforce its internal audit processes to periodically review compliance with cut-off procedures. This practice will involve analyzing the impact of contractual clauses on the period of receipt and use of funds. • Nuestra Escuela will Create documentation of its cut-off policies and procedures to ensure consistent application and understanding among all relevant staff and ensure that they are strictly enforced. • Nuestra Escuela is committed to preventing cut-off errors through a proactive approach from accountants. This involves a combination of robust procedures, leveraging technology, and fostering a culture of accuracy and compliance within the accounting department. By following these best practices, accountants can help ensure the integrity of the financial reporting process. Corrective action plan: Action Date of Compliance Involved areas Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Monthly Executive President Administrative Director Analyze the impact of contractual clauses on the period of receipt and use of funds. Apr 15 – 2025 Jul 15 -2025 Oct 15 – 2025 Ene 15 - 2026 Executive President Administrative Director Training on the best practices and proper cut-off procedures May 8 - 2025 External Consultant Executive President Administrative Director Directors in charge of Programs Complete file with cut-off policies and procedures Jun 20 - 2025 Administrative Director Directors in charge of Programs Actions to complete monthly: • Reconciliations of each account to identify any discrepancies that may indicate cut-off errors. Actions to complete quarterly: • Analyze the impact of contractual clauses on the period of receipt and use of funds. • Training on the best practices and proper cut-off procedures • Complete file with cut-off policies and procedures Contact Person: Ana Yris Guzmán – Executive President

View Audit 351891

Finding 547935 (2024-003)

Significant Deficiency 2024

Clackamas County, Oregon

OR

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us...

Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, and oversight. These will include: • Departments will ensure that all expenses are reviewed to confirm alignment with the specific terms and conditions of the grant before reallocating any charges. • Redistribution of Award expenses will be reviewed and approved by Division Director and/or Finance Grant Manager • Federal Awards quarterly reporting will be reviewed and approved by Finance Grant Manager prior to submission • Journal Entries will be for correcting entries and not move funded expenditures to other funding revenues • All Journal Entries will have complete supporting documentation reviewed and signed by Director level staff at the Division or by Finance Grant Management Anticipated Completion Date: Implementation of controls by March 24, 2025.

View Audit 351867

Finding 547920 (2024-003)

Significant Deficiency 2024

Boys and Girls Clubs of Philadelphia, Inc.

PA

Allowable Costs / Cost Principles Cash Management Period of Performance

View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting ...

View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder and the funder will not seek to recoup out of period costs. Moving forward, the Organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year

View Audit 351859

Finding 547918 (2024-001)

Significant Deficiency 2024

Catholic Community Services of Southern Arizona, Inc.

AZ

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Cash Management

CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest an...

CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest and Procurement procedures. Conflict-of-Interest and procurement policy training sessions were conducted with all levels of staff and will continue to be conducted on a recurring basis. CCS is implementing additional layers of oversight and compliance monitoring. This is the responsibility of the CCS Chief Financial Officer. CCS is committed to continuous improvement, conducting regular internal audits and reviews to verify adherence to federal procurement standards. This is the responsibility of the CCS Revenue Cycle Manager. We are working to ensure that every vendor has a contract on file and all procurement policies are strictly followed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.

View Audit 351857

Finding 547917 (2024-003)

Significant Deficiency 2024

Emory & Henry College

VA

Student Financial Aid Reporting Special Tests & Provisions

2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set f...

2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR Section 685.309(b)(2), the College is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The College does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Context: From a population of 26 students that withdrew officially and unofficially during a term, we tested 3 students and noted those students’ withdrawals were not reported timely or accurately. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Recommendation: We recommend that a review process be put in place to ensure timely and accurate enrollment reporting to NSLDS and additional training on the reporting requirements as needed. Management Response: Management is working with the Registrar’s Office to determine why there was an issue and provide a process that will eliminate any untimely reporting to Clearinghouse moving forward. If the Federal Audit Clearinghouse has questions regarding this plan, please call Angie Edmondson, CFO, 276-944-6755, aedmonds@emoryhenry.edu

View Audit 351842

Finding 547915 (2024-004)

Significant Deficiency 2024

Guilford College

NC

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

2024-004 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Return of Title IV Refunds (Significant Deficiency) Condition: Title IV refunds for the two students tested were calculated incorrectly. Criteria: When the recipient of Title IV grant or loan assistance withdraws fr...

2024-004 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Return of Title IV Refunds (Significant Deficiency) Condition: Title IV refunds for the two students tested were calculated incorrectly. Criteria: When the recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of Title IV grant or loan assistance that the student earned as of the student’s withdrawal date in accordance with 34 CFR 668.22. The institution must return the lesser of the total amount of unearned Title IV assistance or an amount equal to the total institutional charges incurred by the student for the payment period or period of enrollment multiplied by the percentage of Title IV grant or loan assistance that has not been earned by the student. Cause: Controls are not functioning properly. Effect: The amount returned was incorrect for the two students that required refund calculations. Context: From a population of 60 students that official or unofficially withdrew from a payment period, we tested nine and noted that two students required refund calculations. Repeat Finding from a Prior Year: No Recommendation: We recommend the College put procedures in place for accurate preparation and calculation of Title IV refunds. Management Response: We agree the institution must return the lesser of the total amount of unearned Title IV assistance or an amount equal to the total institutional charges incurred by the student for the payment period or period of enrollment multiplied by the percentage of Title IV grant or loan assistance that has not been earned by the student. This issue arose from a lack of leadership and staff training in the Financial Aid Office over the past several years. As a result, proper procedures for calculating and returning unearned Title IV assistance were not consistently. Currently, staff are undergoing comprehensive training in all areas of Title IV and Higher Education Act (HEA) regulations. In the 2024-2025 academic year, the institution hired a new director of financial aid, who has implemented a system to process withdrawals online through Common Origination and Disbursement (COD) and has been working to maintain necessary documentation for accurate refund calculations. Additionally, an updated policies and procedures manual is being finalized to ensure that all staff members have access to the necessary resources and guidelines for compliance. If the Federal Audit Clearinghouse has questions regarding this plan, please call Danielle Pfaff, Controller at 1-336-316-2140 or dpfaff@guilford.edu.

View Audit 351837

Finding 547885 (2024-008)

Significant Deficiency 2024

Blackburn University Dba Blackburn College

IL

Questioned Costs Student Financial Aid Significant Deficiency

Identification and Review • Students clocked in during scheduled class times. Blackburn did not initially educate nor send reminders to students and faculty about students not being able to clock in during class times. • During the 2023-2024 fiscal year, there was a transition in the Dean of Work ro...

Identification and Review • Students clocked in during scheduled class times. Blackburn did not initially educate nor send reminders to students and faculty about students not being able to clock in during class times. • During the 2023-2024 fiscal year, there was a transition in the Dean of Work role. There was not as much oversight of student payroll reports Corrective Actions • The Work Office and Provost Office has increased communication and education about students not being able to work during scheduled class times. Reminders have also been sent out. • The Work Office now has a Dean of Work who is educated about how to run student payroll. Process and Policy Improvements • Starting in the Fall 2024 semester, the Work Office and Provost Office increased awareness and communication regarding students not being allowed to work during scheduled class times. • Student Communication- Student managers communicated with student employees at monthly department meetings and through electronic communication that students are not allowed to clock in during scheduled class times. The exception is when their class is cancelled, and students must send the class cancellation notice (email from Professor or screenshot of Learning Management System announcement) to the Work Office before clocking in during the cancelled class time. Once the cancelled claim information is received, it is added to a spreadsheet maintained jointly by the Provost and Work Office. Professor Communication- The Provost sent an electronic communication to all professors notifying them they must communicate with the Provost and Work Office when they cancel a class. Once the cancelled class information is received, it is added to a spreadsheet maintained jointly by the Provost and Work Office. • Additionally, the Work Office reached out to our time tracking and payroll software vendor to identify a solution to limit students' ability to clock in during scheduled class times. Monitoring and Compliance • The Work Office and Provost Office will dedicate time to educate and remind students and faculty that students are not allowed to work during scheduled class time, and how to report a cancelled class. • The Work Office will dedicate time to double check the student payroll reports before sending them to Human Resources. • The Dean of Work will ensure students are educated in department meetings and through electronic communication that they are not allowed to clock in to work during scheduled class times, and how to report a cancelled class. • The Dean of Work will coordinate with the Provost Office to ensure faculty are educated about students not being able to clock in during scheduled class times, and how to report a class cancellation. • The Dean of Work will randomly select 10 students each payroll to ensure they are not clocking in during their scheduled class times. • The Dean of Work will also ensure that the student payroll is double checked before sending to Human Resources. Reporting and Documentation • Fall 2024 o Student managers educated students during their first department meeting And students also received electronic communication that they could not work during a scheduled class time, and informed them how to report a cancelled class. o The Provost Office sent electronic communication to faculty on the importance of reporting a class cancellation. • Spring 2025 o Student managers educated students during their first department meeting and students also received electronic communication that they could not work during a scheduled class time, and informed them how to report a cancelled class. o The Provost Office sent electronic communication to faculty on the importance of reporting a class cancellation. o The Work Office is facilitating monthly Supervisor trainings. In the February training, supervisors were informed verbally and in writing about students not being able to work during scheduled class times, and what documentation is needed when a class is cancelled. • Fall 2025 o The Work Office will facilitate a Supervisor training before the academic year begins. In the training, we will review policies and procedures with one of them being students not being able to clock in during scheduled class times. Responsible Person for Correction Action Plan: Leslie Johnson, Dean of Work Implementation Date for Corrective Action Plan: 09/03/24

View Audit 351835 Questioned Costs: $1

Finding 547884 (2024-007)

Significant Deficiency 2024

Blackburn University Dba Blackburn College

IL

Questioned Costs Special Tests & Provisions Student Financial Aid

Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students ...

Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students stopped engaging academically • Verify whether R2T4 calculations should have been performed Corrective Actions • Process R2T4 calculations for affected students based on their last date of attendance • Return any unearned Title IV funds • Update students file to reflect accurate withdrawal dates and notify them of any financial obligations resulting from the adjustment • If students are still enrolled in future terms, ensure they understand satisfactory academic progress (SAP) implications Process and Policy Improvements • Implement an early alert system to identify students who cease attendance before the end of the term. • Strengthen collaboration between academic departments, the registrar, and the financial aid office to improve withdrawal tracking • Run monthly withdrawal reports to see when students earn all failing grades. Monitoring and Compliance • Conduct regular audits to ensure compliance with R2T4 regulations and timely student withdrawals • Provide staff training on withdrawal procedures and the importance of accurately tracking last dates of attendance. • Establish a set time to review withdrawal policies and ensure adherence to federal regulations. Reporting and Documentation • Maintain detailed records of all identified cases, R2T4 calculations, and funds returned. • Document all policy and procedural updates made to prevent recurrence. • If required, submit a report to the U.S. Department of Education outlining corrective actions taken. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25

View Audit 351835 Questioned Costs: $1

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