Corrective Action Plans

Finding 409882 (2022-002)

Significant Deficiency 2022

DE

Equipment & Real Property Management § 200.303 § 200.313

Corrective Action PlanYear Ended June 30, 2022Finding 2022-002: EquipmentCondition Found:The University did not complete its physical inventory counts for 10 departments out of the 15 sampled University departments. The University has a total of 70 departments monitoring federal equipment. In addit...

Corrective Action PlanYear Ended June 30, 2022Finding 2022-002: EquipmentCondition Found:The University did not complete its physical inventory counts for 10 departments out of the 15 sampled University departments. The University has a total of 70 departments monitoring federal equipment. In addition, for one item in our sample of 40 physical inspections, we noted the property was not appropriately tagged for identification.Recommendation:The auditors recommend the University enhance its internal control over compliance around establishing property records of newly acquired federally funded equipment in accordance with applicable Federal regulations and completing the necessary physical inventories and reconciliations.University of Delaware Corrective Action Plan:The University agrees with the finding and will strengthen processes including unit and senior leadership accountability around the tagging and surveying of federally funded equipment. The University will implement management and escalation procedures with executive leadership to ensure that accountability for all completed surveys resides with the senior leader. The entire process is being evaluated and controls will be enhanced where needed and training will be expanded to include the importance of timely compliance.Anticipated Completion Date:June 2023Contact Person:Lisa Marra Kelly, Controller, Controller?s Office

View Audit 311956

Finding 406049 (2022-001)

Significant Deficiency 2022

Eastwest Food Rescue

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

EastWest Food Rescue has since implemented a formal expense approval process that requires electronic signatures from authorized individuals before payments will be processed.

View Audit 311592

Finding 403903 (2022-003)

Material Weakness 2022

Aerospace MacHinists Joint Training Committee

WA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26...

Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26, 2023. All policies and procedures related to federal grant agreement compliance will be reviewed and updated on an annual basis by AJAC Directors and Supervisors. Anticipated Completion Date: Completed

View Audit 310790

Finding 403889 (2022-003)

Significant Deficiency 2022

West Alabama Aids Outreach, Inc.

AL

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

Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have institute...

Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have instituted multiple internal processes to confirm administrative fees do not exceed 10% of grant award. The grant biller will prepare a monthly reimbursement schedule in Excel which shows the budgeted amount for each category. The Director of Grants Management reviews and approves this schedule to ensure it meets the grant requirements. Each individual monthly reimbursement form is approved and signed by the Director of Grants Management to confirm accuracy. Then the reimbursement form submitted is entered in a master spreadsheet "Projects by Line Item" which shows original budget, monthly amounts billed for each budget line item, and remaining balance for each item. This is reviewed each month to ensure no amounts, including the administrative costs exceed approved amounts. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO

View Audit 310763 Questioned Costs: $1

Finding 403888 (2022-002)

Significant Deficiency 2022

West Alabama Aids Outreach, Inc.

AL

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followe...

The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followed. For reimbursements, employees will complete an Employee Reimbursement Form which is signed by the employee and employee's direct supervisor. For purchase requests, employees will complete a Purchase Order form which is signed by the employee and the employee's supervisor. The signed form is sent to the finance department where it is entered in Bill.com for payment by accounts payable personnel. The Director of Finance approves the reimbursement or purchase on Bill.com, then the CFO approves and releases for payment. The approved Reimbursement Form or Purchase Order is sent to the Director of Grants Management, and if eligible, attached to the monthly billing to grantor for reimbursement. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO

View Audit 310763

Finding 403822 (2022-007)

Significant Deficiency 2022

Jft Recovery and Veterans Support Services

PA

Procurement, Suspension & Debarment Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.318 § 200.319 § 200.430

Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.

View Audit 310733

Finding 403121 (2022-012)

Material Weakness 2022

State of California

CA

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

Public Health agrees that Form CMS-1539 should be signed. We are exploring reasons why so many forms were not signed, and we will work with our District office management to ensure that they are all signed going forward. Further, we will address this issue at our next meeting of District Managers, ...

Public Health agrees that Form CMS-1539 should be signed. We are exploring reasons why so many forms were not signed, and we will work with our District office management to ensure that they are all signed going forward. Further, we will address this issue at our next meeting of District Managers, District Administrators, and Health Facilities Evaluator Supervisors, and will work to update our training materials as necessary. Finally, we will also explore periodically pulling a sample of completed CMS-1539 forms to verify that signatures are present. Estimated Implementation Date: May 1, 2024 Contact: Elizabeth Moreno, Section Chief Business Operation Section Center for Health Care Quality, Office of Internal Operations California Department of Public Health

View Audit 310237

Finding 403120 (2022-011)

Material Weakness 2022

State of California

CA

Subrecipient Monitoring § 200.303 § 200.332 § 200.501 § 200.513 § 200.521

Public Health’s Center for Preparedness and Response (CPR) agrees that it did not establish a formal risk assessment process over its subrecipients of ELC COVID-19 awards. CPR will establish and document formal procedures for conducting risk assessments of ELC subrecipients. Public Health will also...

Public Health’s Center for Preparedness and Response (CPR) agrees that it did not establish a formal risk assessment process over its subrecipients of ELC COVID-19 awards. CPR will establish and document formal procedures for conducting risk assessments of ELC subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures. CPR also agrees that it did not obtain single audit reports from ELC subrecipients. CPR will develop and implement procedures outlining the process for obtaining single audit reports from subrecipients, which will include a monitoring mechanism to track compliance with the single audit mandate. Estimated Implementation Date: December 2024 Contact: Melissa Relles, Assistant Deputy Director Division of Operations Center for Preparedness and Response California Department of Public Health

View Audit 310237

Finding 403119 (2022-010)

Material Weakness 2022

State of California

CA

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the exist...

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. Prior to this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life-saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, the Health Resources and Services Administration, which encouraged ADAP to reassess its organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help mitigate future findings in ADAP applications. Estimated Implementation Date: Implemented as of April 2022 Contact: Joseph Lagrama, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 310237

Finding 403118 (2022-009)

Material Weakness 2022

State of California

CA

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

The Behavioral Health Administrative support team will endeavor to ensure that timesheets are collected and submitted appropriately. As the payroll system (SCO) and leave accounting (HRIS) are two completely separate programs that do not interact, the Behavioral Health (BH) Administrative Support T...

The Behavioral Health Administrative support team will endeavor to ensure that timesheets are collected and submitted appropriately. As the payroll system (SCO) and leave accounting (HRIS) are two completely separate programs that do not interact, the Behavioral Health (BH) Administrative Support Team will maintain a master file detailing the funding information for each position. For example, if a position is funded by two different grants, the file would reflect the percentage of work associated with each. It must be noted that as employee leave is tracked and maintained in a separate system, the Absence and Additional Time Worked Reports (STD 634) only reflect hours worked and leave used and does not reflect how a position is funded. Additionally, staff who are in Work Week Group E and are exempt from coverage under the Fair Labor Standards Act (FLSA) are not required to document hours worked for payroll purposes. Therefore, this form would only reflect leave credits used in whole-day increments. This means that on their timesheets, you will only find time used to cover full-day leave usage. These are generally our Supervisors and Managers. Estimated Implementation Date: July 2024 Contact: Raberta Gannon, Chief Behavioral Health Administrative Support Services Section Deputy Diretor’s Office, Behavioral Health California Department of Health Care Services

View Audit 310237

Finding 403116 (2022-008)

Material Weakness 2022

State of California

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of He...

The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of Health Care Services transitioned counties away from cost reconciliation financing, and for any state fiscal year after July 1, 2023, counties will no longer be required to submit cost reports. Estimated Implementation Date: July 2023 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 310237

Finding 403115 (2022-007)

Material Weakness 2022

State of California

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

California received $27 billion in State Fiscal Recovery Funds (SFRF) under the American Rescue Plan Act of 2021 to cover costs and mitigate the impacts of the COVID-19 pandemic. States that lost revenue due to the pandemic are permitted to use an amount of SFRF equivalent to their lost revenue, as ...

California received $27 billion in State Fiscal Recovery Funds (SFRF) under the American Rescue Plan Act of 2021 to cover costs and mitigate the impacts of the COVID-19 pandemic. States that lost revenue due to the pandemic are permitted to use an amount of SFRF equivalent to their lost revenue, as calculated pursuant to the U.S. Treasury’s Final Rule, to fund government services. The Department of Finance (Finance) acknowledges that its established review processes did not detect the inclusion of state employee contributions to deferred compensation plans in its revenue loss calculation and that these contributions did not constitute eligible revenue codes as they were not reported as revenues in the state’s basic financial statements. Due to unclear federal guidance, Finance’s original analysis and screening questions accounted for revenue codes that constituted revenues to the state from a budgetary perspective. Finance agrees that this oversight is a material weakness and has since adjusted its approach to the revenue loss calculation by excluding revenue codes that do not constitute revenues from a financial statement accounting perspective. However, Finance maintains that its overall controls and calculation process is sound and disagrees that this oversight was categorized as a material noncompliance finding. As stated in the finding, the overstated revenue loss amount did not impact expenditures reported for fiscal year 2022, and corrective action was taken before this finding and the state’s annual comprehensive financial report were released. The overstated revenue loss amount of $977,898,160 was not transferred from Fund 8506, which was established for the administration of the State Fiscal Recovery Funds received from the federal government, and was not used for the provision of government services. Estimated Implementation Date: January 2024 Contact: Mary Halterman, Assistant Program Budget Manager Federal Funds Cost Tracking & Accountability Unit California Department of Finance

View Audit 310237

Finding 403113 (2022-006)

Material Weakness 2022

State of California

CA

Eligibility Reporting Questioned Costs § 200.303

The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: April 2023 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Em...

The EDD resumed adjudicating all potential eligibility issues as of January 2021 and completed the retroactive determination workload on April 30, 2023. Estimated Implementation Date: April 2023 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403111 (2022-005)

Material Weakness 2022

State of California

CA

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles § 200.303

Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condition...

Given the unprecedented volume of unemployment insurance claims during the federal disaster—approximately 20 million claims compared to 3.8 million during the Great Recession—EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board records in November 2020 to assist in verifying the income of PUA claimants who could not be automatically verified through these procedures. Such claimants were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California WBA of $167, and the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), on February 6, 2024, in accordance with the U.S. Department of Labor (DOL) Unemployment Insurance Program Letter 05-24, the California Employment Development Department (EDD) identified that the processing of PUA income documents and the SEES workloads must be considered resolved due to California’s finality laws. The EDD is prohibited by law from resolving these items by California Unemployment Insurance Code section 1376, which provides that EDD cannot establish overpayments more than one year after the close of the benefit year in which the overpayment was made unless the overpayment is found to be a result of fraud, misrepresentation, or willful nondisclosure. Given that there is no fraud or fault on the part of the individuals identified in these populations, EDD is unable to take the required actions to resolve the workload due to California’s finality law provisions. EDD is expecting a response from DOL agreeing with the application of California’s finality laws to the PUA income verification and the SEES workloads. Estimated Implementation Date: Upon DOL response, to be determined Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403109 (2022-004)

Material Weakness 2022

State of California

CA

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency ...

As reported in the prior year’s response, since fiscal year 2020-21, the Employment Development Department (EDD) has implemented dozens of strict anti-fraud measures and has continued to evaluate and enhance its fraud detection. EDD has also developed internal fraud working groups and a multiagency fraud task force that reviews fraud data and fraud reports on a continual basis and recommends adjustments to filters and tools as necessary. EDD has successfully halted two large fraud scheme attempts over the previous two years and continues to work towards immediate detection and prevention of fraud attempts. EDD will continue to analyze and assess our processes to stay ahead of the ever-evolving fraud landscape. As previously described, EDD implemented the following measures to address the nationwide fraud attempts perpetrated against the new emergency federal benefit programs in 2020-21: • Implemented additional cross-matches in September 2020 to detect multiple claims per address. • Ceased automatically backdating PUA claims under federal rules in September 2020. • Strengthened identity verification procedures in October 2020 by implementing ID.me. • Implemented additional cross-matches in November 2020 against state inmate information. • Vetted applications against law enforcement databases and other tools provided by Thomson Reuters in December 2020 to further curb identity and non-identity fraud. • Established a 1099-G call center to help victims of identity theft deal with any tax-related questions. • Ceased printing Social Security numbers on mailed documents to reduce identity theft risk. • Enhanced benefit card security with Bank of America. • Partnered with state, local and federal law enforcement agencies to support thousands of criminal investigations, arrests, prosecutions and convictions. The EDD has and will continue to evaluate and enhance the fraud detection/prevention tools that have been put in place. Estimated Implementation Date: Annual reassessment to be completed September 2024 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 310237 Questioned Costs: $1

Finding 403107 (2022-003)

Material Weakness 2022

State of California

CA

Eligibility Questioned Costs Allowable Costs / Cost Principles § 200.303

The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility ...

The California Department of Public Health (Public Health) Women, Infants, and Children (WIC) Division had agreed that the WIC Web Information System Exchange (WISE) system does not currently store eligibility history that should be included in the “Cert History Report,” and the initial eligibility data is overwritten when subsequent eligibility information is keyed into WIC WISE. However, WIC WISE does include preventative internal stops or checkpoints that do not allow ineligible individuals to be certified and issued benefits (e.g., over income, not a California resident, no nutrition risk factor, etc.). User acceptance testing vetted these items prior to system implementation in 2019/20. The certification history condition discussed was remediated via a system Defect Correction to WIC WISE that was in user acceptance testing for implementation in Fall 2023. Public Health/WIC has entered Defect Correction #6972 in TFS (Team Foundation Services), the tracking system previously used to capture system changes and defects. The defect correction supports a system change to ensure initial eligibility information is retained when subsequent eligibility information is entered into WIC WISE. Estimated Implementation Date: August 2023 Contact: William Welch, Assistant Division Chief, Operations Women, Infants, and Children Division California Department of Public Health

View Audit 310237

Finding 403106 (2022-002)

Material Weakness 2022

State of California

CA

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Please note that the ELC...

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Please note that the ELC program has been reported in the FY 2022-23 SEFA. Additionally, we will update the procedures to document the SEFA reporting for the ELC program. Estimated Implementation Date: September 2024 Contact: Jennifer Chan, Accounting Administrator II Federal Reporting Unit, Financial Management Division California Department of Public Health

View Audit 310237

Finding 403104 (2022-001)

Material Weakness 2022

State of California

CA

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (...

EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (Database). In addition, the onset of the COVID-19 pandemic created additional issues which ultimately impacted the EDD’s ability to submit timely year-end financials. However, the EDD continues to make progress to gain ground in the department’s efforts to follow the State’s deadlines for submitting year-end financials and entering the cash basis expenditures into the Database. During fiscal year 2022-23, the EDD completed a restructuring within the accounting area which realigned workload amongst the units and provided additional resources in critical areas. These changes will have a lasting effect and help the department to be better positioned going forward in processing the accounting workload and ultimately be able to catch up and submit year-end financials and enter the cash basis expenditures into the Database by the State’s deadlines. In addition, the EDD took lessons learned from the financial audits from the prior two fiscal years to update processes and procedures and applied that knowledge going forward. Also, staff continue to participate in various trainings offered by the Department of Finance and the Department of FI$Cal. In addition, staff work with the control agencies when issues arise that would impact our accounting functions. While the EDD has been behind in submitting year-end financials for prior years, the department is making great progress on catching up. The EDD submitted the last of its fiscal year 2021-22 financials in May 2023 and submitted the last of its fiscal year 2022-23 financials in January 2024. The department is now working on identifying the ineligible payment data needed in order to accurately reflect the cash basis expenditures to enter into the Database. The EDD’s goal is to submit fiscal year 2023-24 financials in November 2024. Similar to the 2020-21 financial audit, the EDD will take the knowledge learned during prior audit seasons and continue to engage with the control agencies, and continue to train and develop staff in order to keep progressing towards the department’s goal of becoming timely with the submission of the year-end financials and the entering of the cash basis expenditures into the Database.

View Audit 310237

Finding 401927 (2022-004)

Significant Deficiency 2022

The Wayside House, Inc. and Subsidiary

MN

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

The Organization will implement control procedures that maintain proper segregation of duties. Federal program reporting shall be prepared by the Staff Accountant or program manager and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The p...

The Organization will implement control procedures that maintain proper segregation of duties. Federal program reporting shall be prepared by the Staff Accountant or program manager and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Staff Accountant, Andrea Vasquez, Chief Operating Officer, Alex Sukalski, New Controller, start date June 3, 2024. Anticipated Completion Date: May 2023

View Audit 309846

Finding 401926 (2022-003)

Significant Deficiency 2022

The Wayside House, Inc. and Subsidiary

MN

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

The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being re...

The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access.

View Audit 309846

Finding 401591 (2022-010)

Material Weakness 2022

Martin University

IN

Questioned Costs Procurement, Suspension & Debarment § 200.303

2022-010 Internal Control and Compliance – Higher Education Emergency Relief Funds (HEERF) Education Stabilization Fund – Assistance Listing No. 84.425E, 84.425F Recommendation: We recommend the institutions strengthen their understanding of the compliance and reporting requirements established by g...

2022-010 Internal Control and Compliance – Higher Education Emergency Relief Funds (HEERF) Education Stabilization Fund – Assistance Listing No. 84.425E, 84.425F Recommendation: We recommend the institutions strengthen their understanding of the compliance and reporting requirements established by grant programs and ensure supporting documentation is maintained to substantiate amounts reported, compliance with requirements is supported by University records, and ensure that federal expenditures are properly identified and classified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged an external consultant in June 2023, hired a new staff accountant in September 2023 and a CFO in November 2023. The University has begun to restructure all accounting and reconciliation functions, including implementation of new accounting software. The University is implementing financial internal controls to improve the financial statements preparation and preparation of the schedule of expenditures and federal awards. Name of the contact person responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 309593 Questioned Costs: $1

Finding 401579 (2022-008)

Significant Deficiency 2022

Martin University

IN

Questioned Costs Eligibility Significant Deficiency § 200.303

2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. E...

2022-008 Eligibility – Pell Awarding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over and under awards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal financial reporting process. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 309593 Questioned Costs: $1

Finding 401563 (2022-009)

Material Weakness 2022

Martin University

IN

Special Tests & Provisions Questioned Costs Student Financial Aid § 200.303

2022-009 Special Tests and Provisions – The Gramm-Leach-Bliley Act (GLBA) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leac...

2022-009 Special Tests and Provisions – The Gramm-Leach-Bliley Act (GLBA) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leach-Bliley Act that have not been completed and documented and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University began engagement with AIS, an IT Managed Service Provider in May 2022 and hired a Director of IT in November 2023. The University is working with AIS and Cowbell to develop and implement a Cybersecurity policy, as well as to provide training for all employees, the Board of Governors, and students. The University has also deployed Cloud Storage backup solutions for all data. Name(s) of the contact person(s) responsible for corrective action: Scharvin Wilson, Director of IT, AIS, IT Managed Services Provider, E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401562 (2022-007)

Significant Deficiency 2022

Martin University

IN

Student Financial Aid Reporting Significant Deficiency § 200.303

2022-007 Reporting – Common Origination and Disbursement (COD) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the entity strengthen its internal controls to ensure that all disbursement dates are reported to COD accurately and ...

2022-007 Reporting – Common Origination and Disbursement (COD) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the entity strengthen its internal controls to ensure that all disbursement dates are reported to COD accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has begun to restructure all accounting and reconciliation functions. The University is implementing financial internal controls to improve the internal financial reporting process. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 309593

Finding 401561 (2022-006)

Significant Deficiency 2022

Martin University

IN

Special Tests & Provisions Questioned Costs Student Financial Aid § 200.303

2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the docu...

2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented policy and procedures that require a review of all official and unofficial withdrawals to have R2T4 calculations on a real time basis to ensure compliance with the Department of Education guidelines on a consistent and regular basis. Internal audits of the process will also be implemented for continuous improvement. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

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