Corrective Action Plans

Finding 560087 (2024-002)

Significant Deficiency 2024

SD

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

Legal Services Corporation FFAL #09-742018 Legal Services Corporation - Basic Field - General FFAL #09-742018 Legal Services Corporation - Basic Field - Native American Special Tests and Provisions - Bonding Requirements for Recipients Significant Deficiency in Internal Control over Compliance and ...

Legal Services Corporation FFAL #09-742018 Legal Services Corporation - Basic Field - General FFAL #09-742018 Legal Services Corporation - Basic Field - Native American Special Tests and Provisions - Bonding Requirements for Recipients Significant Deficiency in Internal Control over Compliance and Noncompliance Condition: The Organization's fidelity bond coverage for 2024 does not meet the minimum level of at least ten percent of its annualized funding level for the previous fiscal year. Minimum coverage required during 2024 is calculated to be $206,414. The Organization's fidelity bond coverage during 2024 is $200,000. Management's Response: Management has increased the fidelity bond coverage to at least 10% of the previous fiscal year's annualized funding level, and will work to maintain coverage of at least 10% of its annualized funding level. Responsible Individuals: Michelle Lovejoy, Program Administrator, Tom Mortland, Executive Director, Lori Stanford, Deputy Director Anticipated Completion Date: April 2025

View Audit 356058

Finding 560045 (2024-001)

Significant Deficiency 2024

Health Projects Center

CA

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Planned Corrective Action: Health Projects Center will address the finding by taking the steps outlined below: 1. Health Projects Center has already contracted a financial consultant in the absence of our Director of Finance, who will provide the expertise needed to oversee internal controls. 2. Hea...

Planned Corrective Action: Health Projects Center will address the finding by taking the steps outlined below: 1. Health Projects Center has already contracted a financial consultant in the absence of our Director of Finance, who will provide the expertise needed to oversee internal controls. 2. Health Projects Center will finalize the year-end trial balance sooner in order to begin the audit sooner. This will prevent the repeat of time restrictions for completion. Person Responsible for Corrective Action Plan: John Beleutz, Executive Director Anticipated Date of Completion: June 30, 2025 fiscal year-end

View Audit 355976

Finding 560011 (2024-003)

Significant Deficiency 2024

Planned Parenthood North Central States

MN

Questioned Costs Period of Performance Allowable Costs / Cost Principles § 200.309

Teenage Pregnancy Prevention Program – Assistance Listing No. 93.297 Recommendation: We recommend the Organization implement stronger internal controls to monitor the period of performance on its federal awards. This includes regular training for staff on compliance requirements and establishing cle...

Teenage Pregnancy Prevention Program – Assistance Listing No. 93.297 Recommendation: We recommend the Organization implement stronger internal controls to monitor the period of performance on its federal awards. This includes regular training for staff on compliance requirements and establishing clear communication channels between finance and program departments. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has reviewed and updated processes to ensure the expenses for the grant period are for the period in question and not merely reported in the General Ledger during the grant period. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: May 1, 2025

View Audit 355925 Questioned Costs: $1

Finding 560009 (2024-002)

Significant Deficiency 2024

Planned Parenthood North Central States

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, the control is adequately documented and retained in accordance with organizational policies and program requirements. Explanati...

Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, the control is adequately documented and retained in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has reviewed the process for intake of patient information and has revised the process outlining the order of the steps that need to be followed in detail. We have also provided staff with additional training and will self audit going forward. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: May 15, 2025

View Audit 355925

Finding 559997 (2024-002)

Significant Deficiency 2024

University of Delaware

DE

Reporting Student Financial Aid Significant Deficiency

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-002: Reporting: Pell Grant Disbursement Data Condition Found: In the auditors’ testing over reporting of Pell Grant disbursement data for the year, they identified a total of twenty-three late submissions of the forty samples reviewe...

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-002: Reporting: Pell Grant Disbursement Data Condition Found: In the auditors’ testing over reporting of Pell Grant disbursement data for the year, they identified a total of twenty-three late submissions of the forty samples reviewed. Recommendation: The auditors recommend the University enhance our internal control over compliance with the federal regulations related to reporting of Pell Grant disbursement data. The University should maintain an appropriate level of staffing to properly perform timely reporting of Pell Grant disbursement information to the COD system. The University should also align the internal control process of reporting Pell Grant disbursement data regardless of semester to eliminate manual errors. University of Delaware Corrective Action Plan: The University agrees with the finding. These late reporting stemmed from two issues. The fall and spring delays were related to errors in the reporting file, which caused the disbursements to fail in processing through the COD via the electronic batch process. The Student Financial Services team identified these errors during their reconciliation process, generally completed weekly. However, during part of the last academic year, this schedule was not consistently followed due to staffing issues. In addition to the fall and spring delays, there were delays in reporting summer Pell disbursements. This delay was directly related to correcting the University’s self-identified issue with the awarding and disbursement of funds during the Winter term related to Finding 2024-001. The University has corrected the processing of Pell during the winter term which will eliminate the sequencing issue. Additionally, the University has implemented electronic batch processing to COD for the summer term and addressed staffing issues to ensure that the reconciliation process continues on a weekly basis. Completion Date: November 1, 2024 Contact Person: Amanda Steele-Middleton, Assistant Vice President for Enrollment Management

View Audit 355907

Finding 559996 (2024-001)

Significant Deficiency 2024

University of Delaware

DE

Questioned Costs Student Financial Aid Internal Control / Segregation of Duties

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-001: Disbursements: Pell Grant Condition Found: The University utilizes a standard term calendar and therefore should calculate federal student aid under Formula 1 (Volume 7, Chapter 1). Under Formula 1, institutions generally calcula...

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-001: Disbursements: Pell Grant Condition Found: The University utilizes a standard term calendar and therefore should calculate federal student aid under Formula 1 (Volume 7, Chapter 1). Under Formula 1, institutions generally calculate a student’s Scheduled Award and splits such award evenly between the fall and spring semesters. The University offers a winter intersession, but did not combine the winter intersession with the fall or spring semester as prescribed by the Federal Student Aid Handbook when calculating federal student aid awards under Formula 1. Instead, the University used Formula 3 to calculate Pell Grant awards and treated the winter intersession as a separate term and awarded Pell Grants to students for the Winter 2024 intersession. In 2024, the University identified that such approach did not align with applicable Title IV regulations and Department guidance. By using Formula 3 to calculate Pell Grant awards, the University exceeded the students’ standard Scheduled Award. The total amount of over-awarded Pell Grants for the 2023-2024 academic period was $698,000. Recommendation: The auditors recommend the University enhance our internal control over compliance with the federal regulations related to disbursement of Pell Grant awards. The University should enhance how we receive, and process external information to ensure the University is properly awarding federal student aid in accordance with Title IV regulations and Department guidance. Additionally, a control should be designed and implemented for the review of such information. University of Delaware Corrective Action Plan: The University agrees with the finding. The University identified this issue as a result of an extensive review of processes, procedures and internal controls within Student Financial Services with the assistance of both external consultants and outside counsel. Through the University’s research, it was determined that this issue began in 2018 with the reintroduction of Year-Round Pell. The over-awarded amount resulted from the misinterpretation of the regulations and associated guidance and use of the incorrect formula. The University self-identified the issue with the Department of Education and is working towards resolution. The questioned costs of $698,000 related to fiscal year 2024 were refunded to the government through COD system as of September 30, 2024. The University is working with the Department of Education to open prior periods to finalize the repayment of an additional $1.9 million which is expected to be completed by June 30, 2025. The University has implemented internal controls which include the use of the Peoplesoft delivered tools to ensure that Pell is awarded using Formula 1 in accordance with Title IV regulations and Department guidance. The information related to winter intersession aid has been updated to specifically address winter Pell and ensure that it meets required regulations for attaching an intersession to a standard term when using Formula 1 for calculating Pell grant eligibility. Additionally, the University has implemented a weekly reconciliation and over-award reports to monitor for compliance. Completion Date: Return of $698,000 Questioned Costs: September 30, 2024 Implementation of Weekly Reconciliations: November 1, 2024 Return of Additional $1,900,000: Anticipated June 30, 2025 Contact Person: Amanda Steele-Middleton, Assistant Vice President for Enrollment Management

View Audit 355907 Questioned Costs: $1

Finding 559919 (2024-001)

Significant Deficiency 2024

Winslow Gardens

RI

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

March 20, 2025 Cognizant or Oversight Agency for Audit Winslow Gardens respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: AAFCPAS, Inc. 50 Washington Street Westborough, MA 01581 Audit period: Decemb...

March 20, 2025 Cognizant or Oversight Agency for Audit Winslow Gardens respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: AAFCPAS, Inc. 50 Washington Street Westborough, MA 01581 Audit period: December 31, 2024 The findings from the December 31, 2024 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 FINDINGS NONE FINDINGS-FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY U.S. Department of Housing and Urban Development 2024-001 Operating Assistance for Troubled Multifamily Housing Projects-CFDA No. 14.164. Recommendation: It is recommended that the Organization review and strengthens its internal controls and procedures to ensure timely transfers to the residual receipts account. This may include implementing additional oversight to ensure compliance with the established timelines. Action Taken: Management is in agreement with this finding. Winslow Gardens is acitvely working with HUD to determine next steps for the residual receipts and a solution to the outstanding Flex Subsidy Loan. If the grantor has questions regarding this plan, please call Joseph Durand at 401-438-7210 Ext. 111 Sincerely yours, Joseph Durand, Chief Financial Officer

View Audit 355860

Finding 559903 (2024-003)

Significant Deficiency 2024

Horizon Education Alliance INC

IN

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Action Taken: HEA will develop a policy and procedure for documenting time and effort for all employees funded under a federal grant that aligns with uniform guidance requirements and train supervisors on this procedure. HEA will review current grants and staffing to ensure this is put in place for ...

Action Taken: HEA will develop a policy and procedure for documenting time and effort for all employees funded under a federal grant that aligns with uniform guidance requirements and train supervisors on this procedure. HEA will review current grants and staffing to ensure this is put in place for all staff funded under a federal grant currently. Upon award of future federal grants, HEA will ensure staff funded under the grant and their supervisors are prepared to implement time and effort reporting according to the policy and procedures. The grant manager and President/CEO will be in charge of ensuring all staff funded under a federal grant are documenting time and effort according to the policy. Contact Person: Sarah Metzler, HEA President/CEO; Aliah Carolan-Silva, HEA VP of Research; Cindi Dixon, HEA Director of Finance Expected Completion Date: July 2025

View Audit 355826

Finding 559881 (2024-005)

Significant Deficiency 2024

Firstfollowers

IL

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Period of Performance – Assistance Listing No. 21.027 Recommendation: We recommend the Organization enhance its internal controls in order to require the maintaining of appropriate supporting documentation to show invoices were reviewed before paid. Explanation of disagreement with audit finding: Th...

Period of Performance – Assistance Listing No. 21.027 Recommendation: We recommend the Organization enhance its internal controls in order to require the maintaining of appropriate supporting documentation to show invoices were reviewed before paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review our procedures surrounding ensuring that the proper accounting period is recorded for each transaction to identify any failures in the process. Name of the contact person responsible for corrective action: Marlon Mitchell Planned completion date for corrective action plan: June 30, 2025

View Audit 355815

Finding 559880 (2024-004)

Significant Deficiency 2024

Firstfollowers

IL

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.329

Reporting – Assistance Listing No. 21.027 Recommendation: We recommend the Organization revise its internal controls to require an independent review of financial and performance reports prior to the reports being filed. The Organization should also ensure appropriate supporting documentation is mai...

Reporting – Assistance Listing No. 21.027 Recommendation: We recommend the Organization revise its internal controls to require an independent review of financial and performance reports prior to the reports being filed. The Organization should also ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure the grant reports are reviewed by a separate individual prior to submitting to funders and document those reviews accordingly. Name of the contact person responsible for corrective action: Marlon Mitchell

View Audit 355815

Finding 559840 (2024-001)

Significant Deficiency 2024

Corpus Christi Housing Authority

TX

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Views of responsible officials and planned corrective action: The Authority’s inspection process includes quality control review of inspection reports to ensure enforcement of Housing Quality Standards (HQS). This includes ensuring that all required inspections are completed as scheduled and that re...

Views of responsible officials and planned corrective action: The Authority’s inspection process includes quality control review of inspection reports to ensure enforcement of Housing Quality Standards (HQS). This includes ensuring that all required inspections are completed as scheduled and that rental assistance is abated for any period during which a unit remains in a failed HQS status due to landlord-required repairs. If a tenant fails to make the required repairs, the Authority will initiate termination proceeds for tenant-caused damages that resulted in the unit failing the HQS inspection. The corrective action has been implemented and Wendy Herman, Vice President of Housing Choice Voucher Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2025.

View Audit 355783

Finding 559701 (2024-008)

Significant Deficiency 2024

Community Christian College

CA

Student Financial Aid Cash Management Significant Deficiency

Condition During our testing, the College was unable to provide evidence of these Direct Loan reconciliations being performed monthly. Corrective Action(s): Community Christian College will include cash management for Direct Loans into our reconciliation process: Monthly meetings will be held each m...

Condition During our testing, the College was unable to provide evidence of these Direct Loan reconciliations being performed monthly. Corrective Action(s): Community Christian College will include cash management for Direct Loans into our reconciliation process: Monthly meetings will be held each month between the Financial Aid Department and the Accounting Department. Monthly reconciliation will begin May 2025.

View Audit 355581

Finding 559700 (2024-007)

Significant Deficiency 2024

Community Christian College

CA

Student Financial Aid Reporting Significant Deficiency

Condition During our testing over the NSLDS reporting requirements, the following deficiencies were noted: 3 of 50 program reporting details did not agree with enrollment details from the enrollment records per the College. 24 of 40 students did not have campus reporting completed within the require...

Condition During our testing over the NSLDS reporting requirements, the following deficiencies were noted: 3 of 50 program reporting details did not agree with enrollment details from the enrollment records per the College. 24 of 40 students did not have campus reporting completed within the required timeframe. Corrective Action(s): Community Christian College has established the following procedure to ensure timely reporting to NSLDS on behalf of our students. The implementation of bi-weekly Change in Status meetings to identify enrollment updates on the campus level will assist us in updating student statuses in CCC’s student information system. Community Christian College will implement a bi-weekly reconciliation process where discrepancies will be flagged, investigated, and corrected during that time. CCC will do a mass reconciliation immediately and begin the bi-weekly reconciliation process in June 2025. Additional measures: The Director of Financial Aid will conduct mandatory NSLDS reporting training for all relevant staff, including how to identify and correct discrepancies and if seen fit, assign a designated enrollment reporting coordinator to work closely with our 3rd party servicer to ensure accurate and timely reporting.

View Audit 355581

Finding 559699 (2024-006)

Significant Deficiency 2024

Community Christian College

CA

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

Condition During our testing over the return of credit balances, the following deficiencies were noted: 􀁸 8 instances where credit balances were not refunded in the required time frame. 􀁸 11 instances where refunds were due to students, but none were posted in the ledger. 􀁸 7 instances where the bal...

Condition During our testing over the return of credit balances, the following deficiencies were noted: 􀁸 8 instances where credit balances were not refunded in the required time frame. 􀁸 11 instances where refunds were due to students, but none were posted in the ledger. 􀁸 7 instances where the balances refunded to students could not be recalculated. Corrective Action(s): Community Christian College has established the following procedure to ensure the timely return of credit balances: The college will revise and formalize the institutions credit balance refund policy to align with federal regulations. The college will implement a centralized tracking log to include fields for credit balance creation date, refund due date, refund issue date, and reconciliation status. The reconciliation process for unresolved credit balances/refunds will begin April 21, 2025 and should be completed by April 25, 2025. CCC will begin developing a tracking process to have in place for next start in June 2025. Additional measures: Community Christian College has established a bi-weekly reconciliation process to take place between the Accounting Department and the Financial Aid Department; this internal audit will ensure the credit balances aligns with federal regulations. Furthermore, the Director of Financial aid will conduct trainings will all parties of both departments.

View Audit 355581

Finding 559698 (2024-005)

Significant Deficiency 2024

Community Christian College

CA

Student Financial Aid Reporting Significant Deficiency

Condition The College did not retain supporting evidence utilized for reporting certain critical information within the FISAP including: 􀁸 Total number of students 􀁸 Total tuition and fees 􀁸 Information on eligible applicants Corrective Action(s): Community Christian College will establish a pre-sub...

Condition The College did not retain supporting evidence utilized for reporting certain critical information within the FISAP including: 􀁸 Total number of students 􀁸 Total tuition and fees 􀁸 Information on eligible applicants Corrective Action(s): Community Christian College will establish a pre-submission review process where the Director of Financial aid will verify that all data reported in the FISAP is accompanied by appropriate supporting evidence: The college will use reports made available by our 3rd Party Servicer to report accurate data each FISAP submission year. This process will begin for the 26-27 Award year.

View Audit 355581

Finding 559697 (2024-004)

Significant Deficiency 2024

Community Christian College

CA

Student Financial Aid Subrecipient Monitoring Significant Deficiency

Condition During our procedures over Return to Title IV requirements, the following deficiencies were noted: 􀁸 7 of 13 Return to Title IV calculations were performed outside of the allowable time frame. 􀁸 1 of 13 withdrawn students did not have a Return to Title IV calculation performed. 􀁸 2 of 6 in...

Condition During our procedures over Return to Title IV requirements, the following deficiencies were noted: 􀁸 7 of 13 Return to Title IV calculations were performed outside of the allowable time frame. 􀁸 1 of 13 withdrawn students did not have a Return to Title IV calculation performed. 􀁸 2 of 6 instances where funds were returned beyond the required time frame. Corrective Action(s): Community Christian College has established the following procedure to ensure timely and compliant processing of Return to Title IV (R2T4) calculations: The College will conduct bi-weekly Change in Status meetings to proactively monitor and identify any enrollment changes within the active student population. This process enables the timely identification of students who have recently withdrawn or are pending withdrawal. By doing so, the institution is able to initiate the R2T4 process promptly and ensure its completion within the federally mandated 30-day timeframe, thereby maintaining compliance and upholding institutional accountability. The bi-weekly Change in Status meetings will begin May 2025 and will continue as such, with adjustments made as needed. Additional measures: Community Christian College’s Registrar will notify respective parties of any enrollment changes; this ensures no changes go unnoticed between biweekly meetings.

View Audit 355581

Finding 559259 (2024-002)

Significant Deficiency 2024

Kansas Hospital Association

KS

Subrecipient Monitoring Eligibility Significant Deficiency

Identification: 93.889 United States Department of Health and Human Services, COVID-19 National Bioterrorism Hospital Preparedness Program, Significant Deficiency; Eligibility Requirement. Corrective Action Plan: The Association will implement controls related to future awards so that federal fundin...

Identification: 93.889 United States Department of Health and Human Services, COVID-19 National Bioterrorism Hospital Preparedness Program, Significant Deficiency; Eligibility Requirement. Corrective Action Plan: The Association will implement controls related to future awards so that federal funding is only provided to eligible recipients once a signed subaward agreement is on file. Anticipated completion date: The Association anticipates completion in 2025.

View Audit 355477

Finding 559085 (2024-007)

Significant Deficiency 2024

County of Ventura

CA

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

Finding 2024-007 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...

Finding 2024-007 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC- 06-0507, 95-6000807 Year: 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: The County Executive Office’s Community Development Management agrees with the recommendation to strengthen the established policies and procedures to ensure documentation of review of reports prior to submittal to HUD. View of Responsible Officials and Corrective Action: The County’s CDBG Policies and Procedures Manual was revised in April 2025 to strengthen internal controls and ensure compliance with program requirements. CDBG program reports shall be reviewed by an independent staff member prior to submission, and documentation of this review shall be maintained in the program’s official files. Name of Responsible Persons: Mary Ann Guariento, CDBG Program Management Analyst Kimberlee Albers, Deputy Executive Officer Implementation Date: April 7, 2025

View Audit 355375

Finding 559072 (2024-001)

Material Weakness 2024

Community Action Partnership of Sonoma County

CA

Procurement, Suspension & Debarment Reporting Significant Deficiency § 200.512

Finding 2024-001: Late Audit Submission Synopsis of Finding The fiscal year audit and reporting package is being submitted after the required due date. Management’s Response Sonoma CAN has contracted with One Abacus to support design and implementation of procedures to maintain real time reconciliat...

Finding 2024-001: Late Audit Submission Synopsis of Finding The fiscal year audit and reporting package is being submitted after the required due date. Management’s Response Sonoma CAN has contracted with One Abacus to support design and implementation of procedures to maintain real time reconciliation and improve accuracy of data as it is entered into the general ledger. Additionally, we have replaced several internal roles with more qualified individuals for the coming year. Contact Person Responsible for Corrective Action: Johnny Nolen, COO + CFO Anticipated Completion Date: 7/1/2025

View Audit 355363

Finding 559038 (2024-003)

Significant Deficiency 2024

American Samoa Community College

AS

Student Financial Aid Reporting Significant Deficiency

Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or t...

Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has strengthened the review process by reinforcing the dual- review control system. In this system:  Control #1 (Financial Aid Coordinator) is responsible for conducting the initial review of the NSLDS Enrollment Report roster, performing data entry, and updating the status.  Control #2 (Financial Aid Manager) performs a secondary review and signs off on all NSLDS roster files before submission. Additionally, a log of all NSLDS submissions will be maintained, with both reviewers' signatures, to ensure proper documentation and accountability. Action Plan: The anticipated completion date for Finding Number 2024-0003 is March 2025

View Audit 355302

Finding 559035 (2024-002)

Significant Deficiency 2024

American Samoa Community College

AS

Student Financial Aid Significant Deficiency Special Tests & Provisions

Finding 2024-002 – Special Tests and Provisions – Return of Title IV Funds Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreemen...

Finding 2024-002 – Special Tests and Provisions – Return of Title IV Funds Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has updated the Financial Aid Handbook, Standard Operating Procedures (SOP), and the R2T4 total days calculation chart to exclude scheduled breaks of five or more consecutive days. To ensure compliance with these updates, the Financial Aid Office conducted a policy review session with the financial aid staff. Additionally, mandatory training sessions were held to reinforce R2T4 calculation procedures, with a specific focus on the proper exclusion of scheduled breaks. The Financial Aid Manager is responsible for calculating the total days for R2T4 purposes each award year. The Financial Aid Officer performs a secondary review to verify the accuracy of these calculations. Action Plan: The anticipated completion date for Finding Number 2024-0002 is March 2025.

View Audit 355302

Finding 559033 (2024-001)

Significant Deficiency 2024

Santa Monica Christian Towers, Inc. Hud Project No. 122sh088

CA

Eligibility HUD Housing Programs Significant Deficiency

Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the ma...

Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the maintenance, management and executive teams. The Managing Agent will reinforce the critical importance of annual unit inspection during its annual Maintenance Conference and its annual Management Conference.

View Audit 355300

Finding 559014 (2024-001)

Significant Deficiency 2024

Community Action Agency of St. Louis County, Inc.

MO

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related ...

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related documentation is contemporaneously completed and appropriately approved to maintain a strong internal control environment. The current intake and eligibility verification procedures was revised to include explicit language requiring staff signatures and approval of eligibility documentation on the date of service. These updated procedures will reflect both in-office and drive-through (if resumed) operations. All relevant staff members will receive updated training on intake documentation requirements, including the importance of contemporaneous staff review and approval. Training materials will be revised to emphasize compliance with federal requirements related to eligibility documentation. While data entry into MIS may still occur post-service, staff will be required to document and date eligibility approvals on the intake fonns at the time of service. Intake forms will now include a section for immediate staff verification with date stamps to reflect real-time approval. Name of Responsible Person: Linda Huntspon, Chief Executive Officer Anticipated Completion Date: Implemented in January 31, 2025

View Audit 355262

Finding 559003 (2024-001)

Significant Deficiency 2024

Indiana Health Centers, Inc.

IN

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and inter...

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken The agency Coordinator will have a training session with each clerk in the agency on the importance of documentation and completion of assessing WIC eligibility. This re-training will include step-by-step instructions. Clerks will be instructed to add notes when needed to explain a client's eligibility, (ex. immigrants and eligibility). Demonstration will be required by each clerk to their supervisor. The re-education will be completed by the end of June 2025 and reported on a log with attendees. Ongoing monitoring will be performed by agency supervisors. They will audit five charts twice a month for each clerk/certifier. In the event, there are deficiencies identified, the supervisor will re-train the clerk/certifier at that time. 1. A folder for each clerk will be kept in a locked cabinet by the agency supervisor. It will contain a log that will consist of the clerk's name, household audited and an analysis of the eligibility that was completed at the certification. 2. Ongoing corrections if needed will be addressed by the agency supervisor or coordinator. Retraining may be requested by clerical staff at any time. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335 or email to tnagel@ihcinc.org.

View Audit 355246

Finding 558976 (2024-001)

Significant Deficiency 2024

Community Health Center Dba Alluvion Health, Inc.

MT

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

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The inform...

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The information provided for the training will be translated to a process document and provided to all registration staff and billers. Colleagues will be expected to use this document as reference guide to improve program adherence. 4. Registration colleagues will participate in a peer review process where each colleague reviews 5 accounts monthly. They will audit demographics and insurance, as well as slide fee program adherence. Feedback will be provided to the colleagues responsible for errors to make corrections. 5. A leadership team member supervising patient registration colleagues will continue to audit 50 patient accounts each month. The accounts selected will have at least one billable medical, behavioral health, SUD, or dental encounter in the audit month. The audit criteria will include identifying the colleague responsible for inputting income information and application of discounts. Errors identified through the audit process will be sent to the colleage responsible for correction. Supervision and coaching will be provided to colleagues while fixing their errors to improve future performance. Responsible Party(s): Melissa Darko, Revenue Cycle Director and Lisa DeMallie, Associate Vice President of Patient Experience Estimated Completion Date: Applications were streamlined in March 2025; training was provided in April 2025 and will be ongoing; a process document will be provided to staff in May 2025; peer reviews were started in February 2025; and auditing has been ongoing and will continue.

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