Corrective Action Plans

Finding 390420 (2023-005)

Material Weakness 2023

DE

Matching / Level of Effort / Earmarking Student Financial Aid Material Weakness § 200.303

2023-005 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.063, and 84.268 – Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally...

2023-005 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.063, and 84.268 – Enrollment Reporting Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third-party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar’s Office will strengthen procedures and reporting practices to ensure timely submission to the National Student Clearinghouse (NSCL) & the National Student Load Data System (NSLDS). The Registrar’s Office will confirm and ensure the submissions to the National Student Clearinghouse (NSCL) corresponds with the timeframe the enrollment is rolled over to the National Student Loan Data System (NSLDS). Name(s) of the contact person(s) responsible for corrective action: Registrar, Dr. Genita Mangum Planned completion date for corrective action plan: July 2024

View Audit 301226

Finding 390416 (2023-009)

Material Weakness 2023

Delaware State University

DE

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation o...

2023-009 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Information Technology is reviewing the written policies and procedures needed to safeguard the University’s applications and data. This includes all 3rd party developed/ implemented applications as well. Name(s) of the contact person(s) responsible for corrective action: Executive Director of Network Services, Russel Weaver & VP/ Chief Information Officer, Darrell McMillion. Planned completion date for corrective action plan: June 2024

View Audit 301226

Finding 390414 (2023-003)

Significant Deficiency 2023

Metropolitan Community College Area

NE

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

COVID-19 Education Stabilization Fund Recommendation: We recommend the College establish a system to ensure reports are submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All HEERF funds ...

COVID-19 Education Stabilization Fund Recommendation: We recommend the College establish a system to ensure reports are submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All HEERF funds have been spent and reports are posted on the website. No additional reports will need to be posted. Name(s) of the contact person(s) responsible for corrective action: Brenda Schumacher Planned completion date for corrective action plan: Prior to Summer 2023

View Audit 301214

Finding 390379 (2023-104)

Material Weakness 2023

Coconino County

AZ

Reporting Internal Control / Segregation of Duties § 200.303

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completi...

Cluster name: WIOA Cluster Assistance Listings number and program name: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration department acknowledges the required financial reports were not all submitted during FY23. The Department did not have a tracking mechanism in place to ensure that all staff were aware of the status of report submission. Additionally, due to recent turnover, the Department did not have staff trained to complete the reports. The Department will complete and submit missing federal financial reports according to the direction provided by the Arizona Department of Economic Security. The County will ensure that the staff responsible for grant reporting have the knowledge and skills necessary to do so in compliance with federal requirements and grant accounting practices. The County has implemented a mechanism to monitor and track reporting due dates and oversee reports to ensure accuracy.

View Audit 301196

Finding 390378 (2023-103)

Material Weakness 2023

Coconino County

AZ

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated complet...

Cluster name: WIOA Cluster Assistance Listings number and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Program 17.278 WIOA Dislocated Worker Formula Grants Contact person: Billy Francis, Executive Director, Coconino Workforce Development Board, County Administration Anticipated completion date: June 30, 2024 Concur. The County Administration Department acknowledges the work experience (WEX) requirement was not met for the Workforce Innovation and Opportunity Act (WIOA) Youth Program Year 2021 allocation. The Department has a tracking mechanism in the financial system and other records to account for the percentage of youth expenditures made on WEX activities. Due to an oversight, the percentage of WEX expenditures in relation to the total allocation was not monitored by staff. Additionally, the amount of WEX funding allocated to the Youth program service provider was insufficient to meet the requirement. The Department will write procedures for the monitoring of earmarking requirements, including WEX, to ensure the roles and responsibilities of staff and key stakeholders are clearly defined. The calculation of funds allocated to the service provider will factor in the level of WEX expenditures needed for the County to meet the requirement. The Department will work with the WIOA Youth program service provider to employ best practices and strategies to recruit eligible in-school and out-of-school youth in need of WEX activities to further their skills and job readiness. The Department will monitor WEX expenditures made by the service provider and provide technical assistance as needed. If the Department projects the County will not meet the threshold for a certain program year allocation, it will seek technical assistance from the Arizona Department of Economic Security.

View Audit 301196 Questioned Costs: $1

Finding 390377 (2023-102)

Material Weakness 2023

Coconino County

AZ

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320 § 200.327

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact persons: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2025 Concur. The Coconino County Flood Control District (FCD) acknowledges price was no...

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact persons: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2025 Concur. The Coconino County Flood Control District (FCD) acknowledges price was not considered as a factor for contractor selection in the procurement of construction services for the Good Neighbor Authority program in accordance with 2 CFR 200 Subpart D Procurement Standards. A procurement was completed for construction-manager at-risk (CMAR) services, authorized by A.R.S. 28-7366, because the FCD believed at that time that the method would also satisfy the federal standards. The CMAR method bases selection on qualification and competence, does not allow for pricing to be requested or considered before making the selection, and transfers the risk of budget overages to the contractor by agreement to a Guaranteed Maximum Price (GMP). After selecting the contractor for Good Neighbor Authority construction projects, the FCD worked closely with the County’s contracted engineering firm to ensure that the GMP was reasonable and cost efficiencies were identified and implemented throughout all stages of the project. The County believes the prices paid as a result of the procurement are reasonable and no excess federal expenditures were made due to the non-federal procurement method that was used in error. FCD fiscal and management staff will receive formal training on 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, also known as the Uniform Guidance, to ensure its requirements are understood. Additionally, the FCD will implement written internal procurement procedures to be used for future procurements so that they are made in accordance with all applicable laws, regulations and policies. The County Finance Department has a designated grant accounting team specializing in compliance with Federal award requirements. The FCD will request technical assistance from this team prior to initiating any procurement with Federal funds to help make sure Federal regulations are considered and met. The Finance Department will provide training to all departments on Uniform Guidance requirements. Training will also be provided on the County’s procurement policies and procedures to help departments gain a complete understanding of the requirements for acquiring goods and services with federal funds. In line with the County’s decentralized finance model in which financial management staff are located within the departments, the responsibility to meet requirements specific to certain federal awards rests with the department that manages the award. The Finance Department will identify the source of funding for procurements requested by departments. Staff who are knowledgeable about Federal procurement requirements and the County’s procurement policies and procedures will review and approve the procurements involving federal awards.

View Audit 301196 Questioned Costs: $1

Finding 390376 (2023-101)

Material Weakness 2023

Coconino County

AZ

Internal Control / Segregation of Duties Reporting § 200.301 § 200.302 § 200.303

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual fi...

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual financial and performance reports were not filed in accordance with the contract. The cash draw reports were completed for the award according to the contractual requirements. Therefore, the federal agency was aware of all expenditures made under the award. The FCD will submit all missing annual financial and performance reports. With assistance from the Finance Department, the FCD will develop procedures to ensure all reporting requirements are met. These procedures will include internal timelines, designated roles and responsibilities, and a tracking mechanism. Additionally, fiscal capacity will be created through the training of an additional staff member in reporting to serve as backup so contractual reporting requirements can be fulfilled when unforeseen challenges arise such as declared emergencies and flood events.

View Audit 301196

Finding 390344 (2023-001)

Material Weakness 2023

Hawaii Pacific University

HI

Allowable Costs / Cost Principles § 200.303

For payroll-related expenditures, management reviewed the duties of individuals and estimated the percentage of their time allocable to the program based upon knowledge of office functions, job duties, and additional demands and tasks related to the COVID-19 pandemic. This review and discussions wit...

For payroll-related expenditures, management reviewed the duties of individuals and estimated the percentage of their time allocable to the program based upon knowledge of office functions, job duties, and additional demands and tasks related to the COVID-19 pandemic. This review and discussions within the management team resulted in the amounts allocated to the HEERF program; the percentage allocations assigned were documented in the calculations used to support the payroll activity recorded during the fiscal year ended June 30, 2023. For non-payroll related expenditures, documented policies were not developed for the HEERF program expenditures and as a result supporting justifications were not consistently documented or maintained. For all expenditures associated with the HEERF program, when documentation was not obtained or maintained, management was basing decisions on all regulations available at the time and decisions made did not violate the intent of the program. The HEERF awards were fully expended as of June 30th, 2022 for the Student Portion and as of September 30th, 2022 for the Institutional Portion. Should similar programs become available in the future, management will develop, in advance of expending funds, documented policies and procedures to administer the program and will maintain documentation demonstrating compliance with program requirements and related institutional policy and procedure. Person Responsible: Assistant Vice President for the Office of Sponsored Projects; Manager, Office of Sponsored Projects; Director of Financial Aid. Targeted Correction Date: n/a, program has ended. Fiscal Year in which Finding Initially Occurred: 2021 (Finding Number 2021-002).

View Audit 301190

Finding 390294 (2023-003)

Material Weakness 2023

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long B...

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long Beach and Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders will be sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator will send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The executive director will ensure supervisory follow-up with each name that shows up in the audit report each pay period by Kronos Reports. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Rob Hays, Executive Director – Bailey Boushay House Expected Completion: April 2024

View Audit 301158

Finding 390290 (2023-002)

Significant Deficiency 2023

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls ove...

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls over the required allowability criteria with regard to payroll expense were not performed for 2 of 25 employees selected for testing. Corrective Action Plan: In addition to timecard approval by supervisors, Mercy San Juan Medical Center Finance will review a sign-off report and obtain written approval via email for unapproved timecards. Person Responsible: Lianna Petrosyan, Director of Finance Expected Completion: April 2024

View Audit 301158

Finding 390289 (2023-001)

Material Weakness 2023

Commonspirit Health

IL

Eligibility Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2023-001 – Eligibility Medicaid Cluster (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Dignity Health Medical Foundation Finding: The Dignity Health Medical Foundation did not retain evidence of Medicaid eligibility being reviewed...

REFERENCE: 2023-001 – Eligibility Medicaid Cluster (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Dignity Health Medical Foundation Finding: The Dignity Health Medical Foundation did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided. Corrective Action Plan: For the Medical Assistance Program, eligibility is validated through a Medi-Cal system website. Dignity Health Medical Foundation personnel have implemented procedures to ensure documentation of eligibility checks are retained. The Clinic Operations manager has instructed staff and supervisors to save proof of eligibility for all months. The Clinic Operations manager checks for retention of eligibility documentation on a random basis and an internal audit will be performed to check for compliance with the documentation retention. Person Responsible: Nicole Hill, Clinic Operations Manager, Dignity Health Medical Foundation. Completion: September 1, 2022

View Audit 301158

Finding 390287 (2023-013)

Significant Deficiency 2023

Commonspirit Health

IL

Procurement, Suspension & Debarment Eligibility Reporting § 200.303

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Manageme...

REFERENCE: 2023-013 – Activities Allowed or Unallowed Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) (Assistance listing No. 93.498) Federal Grantor: U.S. Department of Health and Human Services Facility: Catholic Health Initiatives Colorado (CHIC) Finding: Management did not consistently retain evidence to support that internal controls were in place and operating effectively for approval of invoices with purchase orders and to ensure that bonuses paid to employees related to COVID-19 were eligible to receive the bonus. Corrective Action Plan: This program has ended. CHIC has no additional funding to apply expenses to.

View Audit 301158

Finding 390285 (2023-012)

Significant Deficiency 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

REFERENCE: 2023-012 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did no...

REFERENCE: 2023-012 – Special Tests and Provisions – Return of Title IV Funds SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Good Samaritan College of Nursing and Health Science did not calculate and return Title IV funds in a timely manner to the U.S. Department of Education, within 45 days after the date the institution determined that a student withdrew. Good Samaritan College of Nursing & Health Science did not provide evidence of an effective review process to ensure the timely calculation and return of Title IV funds to the U.S. Department of Education. Corrective Action Plan: To ensure timely returns, Financial Aid Services will incorporate an additional step to the return disbursement process. The additional step will occur after each return to ensure the Common Origination and Disbursement (COD) system shows the return successfully processed for the student. Financial Aid Services will review the student’s disbursement detail history in COD to confirm the return credit adjustment has been applied to the appropriate record and it shows an applied date at ED within the appropriate timeframe for the return. To document this process has been completed, Financial Aid Services will maintain a spreadsheet for all returns. The spreadsheet will document the student, amount of the return, date processed in Financial Aid and Student Accounts, date processed in G5, and date applied at ED per COD. If any issues arise during this review where the return did not successfully apply at ED, Financial Aid Services will review and resolve rejects immediately so the record can move forward and process successfully within the required timeframe. The Dean of Financial Services will validate the report submitted by Financial Aid Services on a monthly basis and submit the document to the President. Both will review and sign the documentation. This documentation will be presented to the GSC Compliance Oversight Committee to ensure monthly verification of time return of Title IV funds. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Expected Completion: April 2024

View Audit 301158

Finding 390280 (2023-007)

Material Weakness 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

REFERENCE: 2023-007 – Special Tests and Provisions – Disbursements to or on Behalf of Students SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Find...

REFERENCE: 2023-007 – Special Tests and Provisions – Disbursements to or on Behalf of Students SFA Cluster (Assistance Listing No. 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science did not send loan notifications to 3 of 30 students selected for disbursement testing for direct loans within 30 days of funds being disbursed. CHI Health School of Radiologic Technology did not send loan notifications to 14 of 14 students for disbursement testing with direct loans within 30 days of funds being disbursed. Corrective Action Plan: This finding has been corrected for Good Samaritan. As of May 2023, for April 2023 loan disbursements, compliance is verified monthly through internal audit of student disbursements. A sample of disbursements is checked for proper and timely notifications. Timeliness of notifications is checked and verified by the Compliance Oversight Committee monthly. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President, Good Samaritan College of Nursing and Health Science David Velasquez, Nuclear Medicine Technologist Coordinator CHI Health School of Radiologic Technology Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390276 (2023-010)

Significant Deficiency 2023

Commonspirit Health

IL

Special Tests & Provisions Eligibility Reporting § 200.303

REFERENCE: 2023-010 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Tech...

REFERENCE: 2023-010 – Special Tests and Provision – Enrollment Reporting Student Financial Assistance Cluster (Assistance listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science and CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Corrective Action Plan: This finding has been corrected for Good Samaritan as of April 2023. Enrollment reporting to the National Student Clearinghouse is conducted 5 times per year and reconciled monthly with loan borrowers to ensure active enrollment. Additional Status Update: The Dean of Enrollment Management validates and reports to the oversight committee regarding the monthly reporting. Monthly reporting to the GSC Compliance committee has verified completion since May 2023 and has been timely thereafter. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science David Velasquez, Nuclear Medicine Technologist Coordinator, CHI Health School of Radiologic Technology Expected Completion: April 2023 (Good Samaritan) and June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390275 (2023-009)

Significant Deficiency 2023

Commonspirit Health

IL

Eligibility Matching / Level of Effort / Earmarking § 200.303

REFERENCE: 2023-009 – Activities Allowed or Unallowed/Eligibility SFA Cluster (Assistance Listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: CHI Health School of Radiologic Technology Finding: CHI Health School of Radiologic Technology did not have adequate internal...

REFERENCE: 2023-009 – Activities Allowed or Unallowed/Eligibility SFA Cluster (Assistance Listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: CHI Health School of Radiologic Technology Finding: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Corrective Action Plan: The financial aid administrator will implement an eligibility checklist to document the review of student documents in line with US Department of Education criteria. The checklist will be completed and a review performed prior sending the financial aid package to the student. Person Responsible: David Velasquez, Nuclear Medicine Technologist Coordinator, CHI Health School of Radiologic Technology Expected Completion: June 2024

View Audit 301158

Finding 390274 (2023-008)

Significant Deficiency 2023

Commonspirit Health

IL

Special Tests & Provisions Student Financial Aid Eligibility § 200.303

REFERENCE: 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress SFA Cluster (Assistance Listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: CHI Health School of Radiologic Technology Finding: CHI Health School of Radiologic Technology had no docum...

REFERENCE: 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress SFA Cluster (Assistance Listing No. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: CHI Health School of Radiologic Technology Finding: CHI Health School of Radiologic Technology had no documented evidence of review and approval of Satisfactory Academic Policy. Additionally, the Satisfactory Academic Policy did not contain all required elements according to federal regulations. Corrective Action Plan: CHI Health School of Radiologic Technology has revised the Satisfactory Academic Policy to incorporate the required components. Additionally, CHI Health will implement documentation procedures including an agenda and minutes for their annual meeting to review the school policies. Person Responsible: Robert Hughes, Program Director, CHI Health School of Radiologic Technology Expected Completion: June 2024

View Audit 301158

Finding 390273 (2023-006)

Material Weakness 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radi...

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan origination and disbursement records to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management for presentation to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science and Financial Aid Services (FAS) David Velasquez, Nuclear Medicine Technologist Coordinator (CHI Health School of Radiologic Technology) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390271 (2023-011)

Material Weakness 2023

Commonspirit Health

IL

Reporting § 200.303 § 200.502 § 200.510

REFERENCE: 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation SFA Cluster (Assistance Listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Management did not have effective int...

REFERENCE: 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation SFA Cluster (Assistance Listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted in an overstatement of the SEFA expenditures reported in the SEFA. Corrective Action Plan: This finding has been corrected. Good Samaritan College of Nursing & Health Science has revised how data will be obtained for the schedule of expenditures of federal awards. Additionally, the G5 report will be provided to National Grant Accounting with the SEFA. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Completion: February 2024

View Audit 301158

Finding 390270 (2023-005)

Material Weakness 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Cash Management § 200.303

REFERENCE: 2023-005 – Cash Management Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samar...

REFERENCE: 2023-005 – Cash Management Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May of 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management and FAS management. This review is presented monthly to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will implement a review control for accounting staff to review the draw down amount provided by the School prior to completing the drawn down. Documentation of the review will be retained. Person Responsible: Judy Kronenberger, President, Good Samaritan College of Nursing and Health Science and Andrea Heffelfinger, Market Director of Accounting (CHI Health) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390269 (2023-004)

Significant Deficiency 2023

Commonspirit Health

IL

Subrecipient Monitoring § 200.303

REFERENCE: 2023-004 – Subrecipient Monitoring Research and Development Cluster (Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, 93.866) Federal Grantor: U.S. Department of Defense, U.S. Department of Health and Human Services Facility: St. Joseph’s Hospital and Medical Center Finding: Whil...

REFERENCE: 2023-004 – Subrecipient Monitoring Research and Development Cluster (Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, 93.866) Federal Grantor: U.S. Department of Defense, U.S. Department of Health and Human Services Facility: St. Joseph’s Hospital and Medical Center Finding: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices are not paid to subrecipients. St. Joseph's Hospital and Medical Center approved and paid duplicate invoices for 2 out of 35 selections. This error was identified by St. Joseph's and they are actively working on getting a refund from the subrecipient. The duplicate payments charged to the grant were $5,514. Corrective Action Plan: St. Joseph’s Hospital and Medical Center research administration identified the duplicate invoice request from the subrecipient and have been actively working with the subrecipient to receive a refund and adjust the federal reimbursement request. New procedures have been implemented for research administration to notify research finance of any incorrect payments and research finance will accrue for the adjustment. Person Responsible: Tomas Cortez, Grant Accounting Manager – St. Joseph’s Hospital and Medical Center Expected Completion: June 2024

View Audit 301158

Finding 390261 (2023-102)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Eligibility Student Financial Aid § 200.303 § 200.513 § 200.521

Cluster name: TRIO Cluster Assistance Listing number and name: 84.042 TRIO – Student Support Services 84.047 TRIO – Upward Bound Award numbers and years: P047A171009, September 1, 2017 through August 31, 2022 P047A170820, September 1, 2017 through August 31, 2023 P042A200873, P042A201342, and...

Cluster name: TRIO Cluster Assistance Listing number and name: 84.042 TRIO – Student Support Services 84.047 TRIO – Upward Bound Award numbers and years: P047A171009, September 1, 2017 through August 31, 2022 P047A170820, September 1, 2017 through August 31, 2023 P042A200873, P042A201342, and P042A200859, September 1, 2020 through August 31, 2025 P047A221154 and P047A221160, September 1, 2022 through August 31, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Eligibility Questioned costs: $5,612 Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Anticipated completion date: June 30, 2024 The District is aware of the importance of maintaining effective internal control over federal awards and ensuring compliance with applicable federal regulations. The District will work with the TRIO project directors at each college to review and revise existing procedures to require an independent and knowledgeable employee review and approve student eligibility determinations prior to awarding program services to them. The District will enhance communication and training efforts to ensure that the TRIO project directors and all staff administering the TRIO programs understand all eligibility requirements and related district-wide policies and procedures. As of March 21, 2024, the questioned costs for the program have been resolved.

View Audit 301142 Questioned Costs: $1

Finding 390260 (2023-103)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C2...

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C210057 and P031C210077, October 1, 2021 through September 30, 2026 P031S220015 and P031S220179, October 1, 2022 through September 30, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Reporting and special tests and provisions Questioned costs: Unknown Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Diana Aguirre-Rosales, Fiscal Director, Maricopa Community Colleges Foundation Anticipated completion date: December 31, 2024 The District is aware of the importance of ensuring that reports submitted are reviewed for accuracy prior to submission and implemented new processes for report review and submission in November 2023. On February 7, 2024, after multiple requests, the U.S. Department of Education (ED) provided the District with access to ED’s reporting system, which will allow the District to timely submit reports. The District will coordinate with the Maricopa Community Colleges Foundation to ensure that the endowment contracts include all necessary federal regulation information and that the investment and disbursement of funds are in accordance with federal regulations.

View Audit 301142 Questioned Costs: $1

Finding 390255 (2023-101)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Student Financial Aid Special Tests & Provisions § 200.303

Cluster Name: Student Financial Assistance Cluster Assistance Listing number and name: 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study Program 84.038 Federal Perkins Loan Program-Federal Capital Contributions 84.063 Federal Pell Grant Program 84.268 Fed...

Cluster Name: Student Financial Assistance Cluster Assistance Listing number and name: 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study Program 84.038 Federal Perkins Loan Program-Federal Capital Contributions 84.063 Federal Pell Grant Program 84.268 Federal Direct Student Loans Award Year: July 1, 2021 through June 30, 2022 Federal Agency: U.S. Department of Education Compliance Requirements: Special tests and provisions Questioned Costs: Unknown Name of Contact Persons: Joshua Lindenberg, District Director of Financial Aid Anticipated Completion Date: December 31, 2024 The Maricopa County Community College District understands the importance of reporting accurate student enrollment statuses and all student enrollment status changes to the National Student Loan Database (NSLDS) for the Pell and Direct Loan programs. System improvements were completed in June 2023 to reduce and prevent enrollment reporting errors. The District will continue to enhance internal controls by expanding procedures to proactively monitor, detect, and correct unresolved enrollment reporting errors and will conduct semi-annual quality assurance reviews of student accounts to ensure enrollment data is reported appropriately to the NSLDS. The district will assess and enhance the existing enrollment reporting transmission schedule, documenting and disseminating a final copy to staff to ensure optimal efficiencies and reduce enrollment reporting errors caused by the timing of data transmission and error processing.

View Audit 301142 Questioned Costs: $1

Finding 390198 (2023-001)

Significant Deficiency 2023

St. Lukes Health Network, Inc. and Controlled Entities

PA

Student Financial Aid Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal ...

2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network has controls for the student financial aid program, monitored by the Student Financial Aid Office. The Network agrees with the finding regarding the retention of support and documentation of the reviews and approvals in the financial aid process. Going forward the Network will enhance the documentation and retention of support of proper review and approval that will evidence the appropriate segregation of duties. The Network is implementing this process beginning in Q4 of FY2024. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.

View Audit 301103

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