Corrective Action Plans

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

Finding 547883 (2024-006)

Significant Deficiency 2024

Blackburn University Dba Blackburn College

IL

Reporting Special Tests & Provisions Student Financial Aid

Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting d...

Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting delays or errors, whether due to system malfunctions, manual processing errors, or lack of oversight Corrective Actions • Submit corrected enrollment data to NSLDS for all affected students using our National Student Clearinghouse. • Ensure that all errors identified during the audit are addressed, and follow up to confirm the corrections are reflected in NSLDS. • Notify any impacted students of any changes in their enrollment status and provide necessary support if their loan repayment terms are affected. Process and Policy Improvements • Develop and implement clear policies to ensure accurate and timely submission of enrollment data within the required 30-day reporting window or in accordance with scheduled reporting intervals. • Automate the enrollment reporting process where possible to minimize manual data entry errors. • Establish cross-departmental communication protocols to ensure timely updates on student withdrawals, graduations, and status changes. • Create detailed documentation of reporting procedures for staff training and compliance purposes. Monitoring and Compliance • Implement regular reconciliation checks between our student information system (SIS) and NSLDS to ensure data accuracy • Conduct periodic internal audits to identify discrepancies before external audits occur • Designate staff to oversee enrollment reporting and ensure adherence to federal regulations. Staff Training • Provide comprehensive training for staff responsible for enrollment reporting on NSLDS requirements, deadlines, and best practices • Offer training sessions as regulations change or system updates occur. Reporting and Documentation • Maintain records of all corrected data submissions, audit results, and communications with NSLDS • Document procedural changes and staff training efforts Responsible Person for Correction Action Plan: Dianna Ruyle, Director of Records, Registration and Advising Implementation Date for Corrective Action Plan: Immediately and ongoing

View Audit 351835

Finding 547745 (2024-003)

Significant Deficiency 2024

Rural Resources Community Action

WA

Reporting Internal Control / Segregation of Duties Significant Deficiency

FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control sur...

FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submited timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller

View Audit 351833

Finding 547733 (2024-006)

Significant Deficiency 2024

County of Orange, California

CA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.430

2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance an...

2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.430, Compensation – Personal Services, states that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable and properly allocated. Condition: During our testing of the Sheriff Department’s compliance with allowable costs/cost principles requirements, we noted that thirty-three (33) of forty (40) overtime cost calculations were miscalculated. Cause: Equitable sharing funds may not be used for salaries, except under certain provisions outlined in Section V.B.3 of the Equitable Sharing Guide including overtime. The Sheriff’s Department calculates the allowable portion of personnel salaries using a separate template that contained a formula error which inaccurately calculated the total salaries costs allocated to the program. The Sheriff’s department did not have internal controls in place to ensure that the allowed salaries were being calculated correctly. However, the error was detected after the 5th out of 6 months in which these types of costs were allocated to the program. Effect: Salary costs were allocated to the program in an incorrect amount. Questioned Costs: Our testing resulted in questioned costs in the amount of $3,550. However, the total questioned costs for the total population was $23,409. Context/Sampling: A sample of forty (40) individuals were selected from a population consisting of (840) payroll transactions. Repeat Finding from Prior Years: No. Recommendation: We recommend the Sheriff’s Department establish and maintain internal controls to ensure the overtime calculations are being accurately allocated to the program. Management Response and Corrective Action: 1. Person Responsible: Tiffany Mui, Fiscal Administrator 2. Corrective Action Plan: a. Staff corrected the formula error in the Overtime (OT) calculation workpapers. Detailed workpapers, including formulas, will be reviewed by Fiscal Administrator. b. Updated desk procedures for Sheriff’s Narcotics task will include updated OT calculation change. Procedures will be reviewed and initialed by Fiscal Administrator and Sr. Fiscal Manager. 3. Anticipated Implementation date: March 2025

View Audit 351824 Questioned Costs: $1

Finding 547730 (2024-010)

Significant Deficiency 2024

County of Orange, California

CA

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

2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance ...

2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: For two (2) out of three (3) project application summary reports tested, the OCPW did not retain evidence to document the individual who reviewed and approved the required reports. Cause: The department’s procedures did not include documenting the review and approval of the reports prior to submission. Effect: Ineffective controls over this area of compliance could result in reports that are inaccurate or incomplete being submitted or disclosed to the granting agency. Questioned Costs: No questioned costs were identified as a result of our audit procedures. Context/Sampling: A non-statistical sample of three (3) of nine (9) Grant Project Application Summary Reports were selecting for testing. The condition above was identified during our procedures over reporting testing. Repeat Finding: No. Recommendation: We recommend the OCPW department revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. Management Response and Corrective Action: 1. Person Responsible: • FEMA Public Assistance Grants Coordinator – Responsible for completing reports, uploading documents to the FEMA Grants Portal, and ensuring accurate records. • OCPW Emergency Manager Responsible for reviewing, approving, and submitting project applications. 2. Corrective Action Plan: • Revised Procedures for Review and Approval: i. The FEMA Public Assistance Grants Coordinator will be responsible for completing the Project Application Summary Reports. ii. Upon completion, the Grants Coordinator will upload all supporting documents into the FEMA Grants Portal. The system automatically timestamps each document and records the name of the individual who uploaded it, ensuring clear documentation of the review process. iii. After all required documents are uploaded, the OCPW Emergency Manager will be notified that the project application is ready for review. iv. The OCPW Emergency Manager will then: 1. Review the submitted documents in the FEMA Grants Portal. 2. Confirm that the reported costs align with the information provided by the reporting County agency. 3. Approve and submit the project application to Cal OES and FEMA for project approval. • Retention of Documentation: i. The FEMA Grants Portal serves as the official system of record, ensuring all uploaded documents are timestamped and traceable. ii. All project application approvals, cost documentation, and required forms will be retained electronically within the system for audit and compliance purposes. • Training and Implementation: i. Staff responsible for grant reporting will receive training on the revised process, including proper document upload procedures and compliance expectations. ii. The updated process will be implemented immediately. • Monitoring and Compliance: i. The OCPW Emergency Manager will conduct semiannual internal reviews of project applications to ensure compliance with the updated procedures. ii. Any issues identified during internal reviews will be addressed through additional staff training and process improvements. 3. Anticipated Implementation date: Immediate, March 18, 2025 • Staff Training: Within 30 days • Semiannual Compliance Review: Beginning next quarter i. First review will take place May 1, 2025. Followed by another review in October 2025.

View Audit 351824

Finding 547704 (2024-008)

Significant Deficiency 2024

County of Orange, California

CA

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2024-008 Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Health Care Services Award No. and Year: Various Compliance Requirements: Eligibility Type of Finding: Significa...

2024-008 Program: Medicaid Cluster Federal Financial Assistance Listing Number: 93.778 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Health Care Services Award No. and Year: Various Compliance Requirements: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: Title 42 Chapter IV Subchapter C Part 435 Subpart J Section 435.916, Regularly Scheduled Renewals of Medicaid Eligibility, states that the agency must renew MAGI-based determination of eligibility once every 12 months and no more frequently than once every 12 months. For non- MAGI beneficiaries, entities must renew eligibility at least once every 12 months. Condition: During our testing of the Social Service Agency’s (SSA) provisions for eligibility requirements, we noted that for one (1) of sixty (60) samples tested the department did not suspend, or pause, program eligibility despite being over the income limit for MAGI. Cause: The SSA department did not ensure the department’s policies and procedures relating to eligibility determination were followed. We noted that when a participant is determined to be over the income limit for MAGI, the participant is placed on a “soft pause” until a determination of eligibility under non-MAGI or Covered California is made. The department had erroneously marked the application as complete rather than placing the account on “soft pause” which caused the case to auto-renew. Effect: The County’s control was not consistently followed which caused an inaccurate determination of eligibility. Questioned Costs: None noted. Context/Sampling: A non-statistical sample of sixty (60) out of all active program participants were selected for testing. The condition noted above was identified during our procedures related to eligibility. Repeat Finding: No. Recommendation: We recommend the SSA department adhere to their policies and procedures to ensure that participant eligibility determinations and redeterminations are performed accurately. Management Response and Corrective Action: 1. Person Responsible: Michael Ueda, Human Services Manager and Yesenia Zapien, Human Service Manager 2. Corrective Action Plan: SSA will add administrative controls to track cases in soft pause to ensure eligibility determinations and redeterminations are performed accurately. Additionally, staff will be reminded of the policy and procedures surrounding soft pause. 3. Anticipated Implementation date: May 2025

View Audit 351824

Finding 547613 (2024-001)

Significant Deficiency 2024

Tasc of Northwest Ohio

OH

Reporting Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings ...

Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT None FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2024-001 Improper controls over allocation of salaried employees time and effort. Recommendation: Implement strategy of using time and effort documentation in determining payroll costs charged to grants Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TASC of Northwest Ohio will implement a policy that includes a lookback and reconciliation to time and effort recorded by salaried employees to ensure that time is accurately charged to grants. Name(s) of the contact person(s) responsible for corrective action: Jason Pollick, Executive Director Planned completion date for corrective action plan: January 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Sonya Sparks at 419-242-9955.

View Audit 351782

Finding 547600 (2024-007)

Significant Deficiency 2024

Housing Authority of the County of Monterey

CA

Questioned Costs HUD Housing Programs Special Tests & Provisions

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial...

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – N. Special Tests and Provisions - Reasonable Rent Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Reasonable Rent. The Authority must do the following: The Authority must determine that the rent to owner is reasonable at the time of initial leasing. Also, the Authority must determine reasonable rent during the term of the contract (a) before any increase in the rent to owner, and (b) at the HAP contract anniversary if there is a 5 percent decrease in the published Fair Market Rent in effect 60 days before the HAP contract anniversary. The Authority must maintain records to document the basis for the determination that rent to owner is a reasonable rent (initially and during the term of the HAP contract) (24 CFR sections 982.4, 982.54(d)(15), 982.158(f)(7), and 982.507). Condition: Based upon inspection of the Authority’s files and discussion with management, there were newly leased units for which the evaluation of rent reasonableness was not performed. Context: There were approximately 821 newly leased units. Of a sample size of forty-two (42) newly leased units, one (1) unit's documentation of reasonable rent was not available for examination. Our sample size is statistically valid. Known Questioned Costs: $16,685 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to reasonable rent. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the special tests and provisions type of compliance related to reasonable rent. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the significant deficiency in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Gabriela Rivero, Executive Assistant, will be responsible to implement this corrective action by June 30, 2025.

View Audit 351761 Questioned Costs: $1

Corrective Action Plans

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