Corrective Action Plans

Finding 403083 (2023-001)

None 2023

CA

Subrecipient Monitoring Reporting

Ricardo Ornelas, Chief Financial Officer, reviewed the processes for preparation of the SEFA and incorporated additional procedures to ensure errors are identified and corrected prior to submission, including multiple levels of review for the prepared SEFA to ensure the information reported in the S...

Ricardo Ornelas, Chief Financial Officer, reviewed the processes for preparation of the SEFA and incorporated additional procedures to ensure errors are identified and corrected prior to submission, including multiple levels of review for the prepared SEFA to ensure the information reported in the SEFA agrees to the contract, amendment(s), payment confirmation, and underlying accounting records. In addition, management will adopt the recommendations above.

View Audit 310230

Finding 403079 (2023-002)

None 2023

El Proyecto Del Barrio, Inc.

CA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

El Proyecto will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. El Proyecto will continue to provide ongoing training to clinic staff who evaluate the sliding fee application at its clin...

El Proyecto will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. El Proyecto will continue to provide ongoing training to clinic staff who evaluate the sliding fee application at its clinic locations. The training will consist of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. Person Responsible: Leticia Vasquez Position of Responsible Party: Billing Manager Completion Date: September 30, 2024

View Audit 310230 Questioned Costs: $1

Finding 403076 (2023-002)

Significant Deficiency 2023

Lone Pine Economic Development Corporation and Trust

CA

Reporting § 200.512

Comments: Management agrees with the finding. Actions: Management will implement policies and procedures to ensure the financial statement audit is submitted to the Federal Audit Clearinghouse within the required timeframe.

View Audit 310223

Finding 403073 (2023-001)

Significant Deficiency 2023

Lone Pine Economic Development Corporation and Trust

CA

Reporting Internal Control / Segregation of Duties

Comments: Management agrees with the finding. Actions: Management will make the required monthly transfer to the replacement reserve cash account. Management will transfer $$69,604 to the replacement reserve cash account.

View Audit 310223

Finding 403070 (2023-001)

Material Weakness 2023

Montgomery County Board of Education

AL

Questioned Costs Matching / Level of Effort / Earmarking Special Tests & Provisions

Response/Views: We agree with the finding and have already put actions in place to correct it. Corrective Action Planned: We have notified current Architects, Engineers, and General Contractors regarding the compliance with the Davis Bacon Act. In fact, some have already provided Addendums to our cu...

Response/Views: We agree with the finding and have already put actions in place to correct it. Corrective Action Planned: We have notified current Architects, Engineers, and General Contractors regarding the compliance with the Davis Bacon Act. In fact, some have already provided Addendums to our current contracts or have agreed to do so. Anticipated Completion Date: This has been initiated and anticipated to be completely complied with by September 30,2024 Contact Person(s): Mr. Chad Anderson, Executive Director of Operations Mr. Arthur Watts, Chief School Financial Officer

View Audit 310222 Questioned Costs: $1

Finding 403068 (2023-002)

Material Weakness 2023

Harney County School District No. 4

OR

Material Weakness Internal Control / Segregation of Duties Special Tests & Provisions

The District Business Manager will establish internal controls to ensure contractors meet the Davis-Bacon prevailing wage requirements prior to charging expenses to the Education Stabilization Fund grants.

View Audit 310217

Finding 403066 (2023-001)

Material Weakness 2023

One Roof Community Housing

MN

Procurement, Suspension & Debarment Eligibility

Name of contact person – Peter Krieger, Housing Development & Construction Director Corrective action – Management will implement the suspension and debarment testing procedures for all contracts as part of the vendor selection process going forward, and are in the process of updating the financial...

Name of contact person – Peter Krieger, Housing Development & Construction Director Corrective action – Management will implement the suspension and debarment testing procedures for all contracts as part of the vendor selection process going forward, and are in the process of updating the financial policies to include this language. Proposed completion date – Management will implement the above procedures immediately. The procurement policy will be within the Financial Policies that will be presented to the finance committee no later than July 2024 for recommendation of Board approval at the next Board meeting (no later than September 2024).

View Audit 310213

Finding 403065 (2023-007)

Significant Deficiency 2023

Resilience: Advocates for Ending Violence

MI

Equipment & Real Property Management

Finding 2023-007: Crime Victim Assistance Equipment Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommend...

Finding 2023-007: Crime Victim Assistance Equipment Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the maintenance of detailed fixed asset records that include all specified elements. In addition, the Organization should perform a physical inventory of the property and reconcile the results with fixed asset records at least once every two years to help prevent loss, damage, or theft of the property. Action Taken: The Organization will establish a standard operating procedure that requires the maintenance of detailed asset records and the performance of a documented physical inventory of the assets acquired with federal funds on an annual basis. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.

View Audit 310209

Finding 403064 (2023-006)

Significant Deficiency 2023

Resilience: Advocates for Ending Violence

MI

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: Septemb...

Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures to require the documented review and approval of all indirect calculations, cash management requests for funds and performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.

View Audit 310209

Finding 403063 (2023-005)

Material Weakness 2023

Resilience: Advocates for Ending Violence

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Finding 2023-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: Sep...

Finding 2023-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.

View Audit 310209

Finding 403062 (2023-002)

Significant Deficiency 2023

American Diabetes Association

VA

Procurement, Suspension & Debarment § 200.213 § 200.318

American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding procurement, suspension, and debarment. In response to the audit finding, ADA is taking the following corrective actions to address the audit recommendati...

American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding procurement, suspension, and debarment. In response to the audit finding, ADA is taking the following corrective actions to address the audit recommendations: 1) Financial Services will communicate annual reminders of the existing policy relating to procurement policies including the requirement to evaluate a firms status relating to federal suspension and debarment. 2) Federal grant program management will develop and utilize a checklist to ensure that all procurement steps are completed prior to forming a relationship with a potential vendor.

View Audit 310207

Finding 403061 (2023-001)

Significant Deficiency 2023

American Diabetes Association

VA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.308 § 200.403 § 200.430

American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding activities allowed or unallowed and allowable costs. In response to the audit finding, ADA is taking the following corrective actions to address the audit...

American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding activities allowed or unallowed and allowable costs. In response to the audit finding, ADA is taking the following corrective actions to address the audit recommendations: 1) Financial Services will communicate annual reminders of the existing policy relating toweekly completion and manager review of time records to all ADA team members. 2) Federal grant program management will perform weekly monitoring of all time recordsapplicable to federal awards to ensure that time is reviewed and approved by a manager with knowledge of staff activities so that ADA conforms to federal regulations regardingactivities allowed or unallowed and allowable costs. 3) Financial Services will execute a reimbursement request only once all time is reviewed and approved by a manager with knowledge of staff activities.

View Audit 310207

Finding 403059 (2023-002)

Material Weakness 2023

Pasco County Housing Authority

FL

Material Weakness

The Authority will complete and submit budgets applicable to each of its Program properties prior to the beginnings of subsequent fiscal years. The Authority’s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of July 1, 2024. Corrective Action T...

The Authority will complete and submit budgets applicable to each of its Program properties prior to the beginnings of subsequent fiscal years. The Authority’s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of July 1, 2024. Corrective Action The Authority will complete and submit budgets applicable to each of its Program properties prior to the beginnings of subsequent fiscal years. The Authority’s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of July 1, 2024.

View Audit 310197

Finding 403058 (2023-001)

Material Weakness 2023

Pasco County Housing Authority

FL

Material Weakness

The Authority will perform annual inspections on each of its Program properties. The Authority’s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of July 31, 2024. Rural Rental Assistance Payments Program – Assistance Listing No. 10.427; Grant Pe...

The Authority will perform annual inspections on each of its Program properties. The Authority’s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of July 31, 2024. Rural Rental Assistance Payments Program – Assistance Listing No. 10.427; Grant Period: Fiscal Year-End September 30, 2023 Corrective Action The Authority will perform annual inspections on each of its Program properties. The Authority’s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of July 31, 2024. Corrective Action The Authority will perform annual inspections on each of its Program properties. The Authority’s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of July 31, 2024.

View Audit 310197

Finding 403038 (2023-001)

Significant Deficiency 2023

United Planning Organization

DC

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management acknowledges the recommendations associated with this finding and will ensure that—going forward—all reconciliations will be completed timely.

View Audit 310186

Finding 403031 (2023-004)

Significant Deficiency 2023

Riverside Healthcare Association, Inc.

VA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action: Additional training for Registrar staff is in progress to include a full review of processes and controls related to monthly Student Information System – Clearinghouse – NLSDS reconciliation. This review includes a review of how program start dates (semester and session) vs. cours...

Corrective Action: Additional training for Registrar staff is in progress to include a full review of processes and controls related to monthly Student Information System – Clearinghouse – NLSDS reconciliation. This review includes a review of how program start dates (semester and session) vs. course starts affect reporting, as well as how multiple student status changes to registration affect reporting. The College’s third-party servicer, National Student Clearinghouse, is assisting in this training to include the update of policies, processes, and controls, as well as the maintenance of evidentiary documentation. Contact Person: Lori Arnder, Registrar & Enrollment Manager Anticipated Completion Date: July 31, 2024

View Audit 310169

Finding 403030 (2023-003)

Significant Deficiency 2023

Riverside Healthcare Association, Inc.

VA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action: A monthly reconciliation process has been put into place to include control reporting of all status changes to ensure accuracy and timeliness of student status changes from the college’s student information system to National Student Clearinghouse to NSLDS. Contact Person: Lori Ar...

Corrective Action: A monthly reconciliation process has been put into place to include control reporting of all status changes to ensure accuracy and timeliness of student status changes from the college’s student information system to National Student Clearinghouse to NSLDS. Contact Person: Lori Arnder, Registrar & Enrollment Manager Anticipated Completion Date: July 1, 2024

View Audit 310169

Finding 403029 (2023-002)

Material Weakness 2023

Riverside Healthcare Association, Inc.

VA

Student Financial Aid

Corrective Action: Additional training is in progress for Financial Aid & Student Accounts staff to include a full review of processes and controls related to credit-balance payments within 14- days. The College’s third-party servicer, Global Financial Services, is assisting in this training to incl...

Corrective Action: Additional training is in progress for Financial Aid & Student Accounts staff to include a full review of processes and controls related to credit-balance payments within 14- days. The College’s third-party servicer, Global Financial Services, is assisting in this training to include the update of policies, processes, and controls, as well as the maintenance of evidentiary documentation. Contact Person: Michael Hamilton, Dean of Student Success Anticipated Completion Date: July 31, 2024

View Audit 310169

Finding 403028 (2023-001)

Material Weakness 2023

Riverside Healthcare Association, Inc.

VA

Corrective Action: Additional training is in progress for Financial Aid & Student Accounts staff to include a full review of processes and controls related to monthly COD/NLSDS reconciliation. The College’s third-party servicer, Global Financial Services, is assisting in this training to include the...

Corrective Action: Additional training is in progress for Financial Aid & Student Accounts staff to include a full review of processes and controls related to monthly COD/NLSDS reconciliation. The College’s third-party servicer, Global Financial Services, is assisting in this training to include the update of policies, processes, and controls, as well as the maintenance of evidentiary documentation. Contact Person: Michael Hamilton, Dean of Student Success Anticipated Completion Date: July 31, 2024

View Audit 310169

Finding 403024 (2023-002)

Significant Deficiency 2023

Word of Life Fellowship, Inc. and Subsidiary

NY

Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Our plan to correct issues associated with GLBA compliance by sections are stated as below: For 16 CFR § 314.4(c)(l-8) (partially implemented) We plan to implement and correct all deficiencies related to the multi-factor authentic...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Our plan to correct issues associated with GLBA compliance by sections are stated as below: For 16 CFR § 314.4(c)(l-8) (partially implemented) We plan to implement and correct all deficiencies related to the multi-factor authentication on our VPN, by implementing a new software and hardware solution that will sufficiently address the lack of MFA on that side. One of our other software products used for Financial Aid administration will require either a replacement, or compensating control/exception placed into our policies and risk management policies. Modify our asset risk assessment policy to include steps to annually review access to all financial applications to determine whether the user is still required to access the systems. For 16 CFR § 314.4(f)(3) (partially implemented) We plan to change our risk management policy to do regular (at least annually) checks on all of our vendors supplying information on whether they comply with GLBA in their security, disaster recovery and incident response controls to keep our data confidential, keep its integrity and require its availability. For 16 CFR § 314.4(i) (not implemented) Adjust our information security policy to include reporting to our board of directors annually with a written report about the Program and its compliance with GLBA. Person Responsible for Corrective Action Plan: Matthew Hager, Director of IT. Anticipated Date of Completion: 7/31/2024

View Audit 310166

Finding 403021 (2023-001)

Material Weakness 2023

Word of Life Fellowship, Inc. and Subsidiary

NY

Internal Control / Segregation of Duties Student Financial Aid Material Weakness

Inaccurate and Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: In response to the identified discrepancies, we have developed a comprehensive action plan aimed at enhancing our procedures and mitigating the risk of similar issues in the future. 1. Review of Title IV Fund Retur...

Inaccurate and Untimely Returns of Title IV Funds (R2T4) Planned Corrective Action: In response to the identified discrepancies, we have developed a comprehensive action plan aimed at enhancing our procedures and mitigating the risk of similar issues in the future. 1. Review of Title IV Fund Return Processes: • Conducted a thorough review of our current Title IV fund return processes to identify the underlying causes of the discrepancies. • Assessed current procedures, documentation, and staff training protocols to pinpoint areas needing improvement. 2. Implementation of Bi-Weekly Enrollment Status Reviews: • Establish a process to review student enrollment status every two weeks to identify students who have withdrawn or stopped attending. • Designate specific team members responsible for conducting these bi-weekly reviews. • Provide comprehensive training for designated staff on the importance and procedures of Return to Title IV (R2T4) calculations. 3. Standardized Communication Process: • Develop a standardized process for promptly communicating student withdrawals to the third-party servicer after each bi-weekly review. • Ensure clear guidelines and timelines for communication to prevent delays. 4. Monitoring and Documentation: • The Financial Aid Office will document all actions taken under this corrective action plan. • Maintain detailed records of bi-weekly reviews, communications with the third-party servicer, and subsequent R2T4 calculations. 5. Compliance and Success: • By implementing this corrective action plan, the Financial Aid Office will ensure timely and accurate R2T4 calculations. • Maintain compliance with federal regulations and prevent delays through regular reviews, proper documentation, and prompt communication. Person Responsible for Corrective Action Plan: Alex Hackett, Director of Financial Aid Anticipated Date of Completion: 7/31/2024

View Audit 310166

Finding 403020 (2023-001)

Significant Deficiency 2023

Mayo Clinic

MN

Matching / Level of Effort / Earmarking Student Financial Aid Allowable Costs / Cost Principles

Federal Program Information Federal Agency: United States Department of Education Federal Cluster: Student Financial Assistance Assistance Listing No.: 84.268, Federal Direct Student Loans (Direct Loans) Award Periods: July 1, 2022 through June 30, 2023; July 1, 2023 through June 30, 2024 Correctiv...

Federal Program Information Federal Agency: United States Department of Education Federal Cluster: Student Financial Assistance Assistance Listing No.: 84.268, Federal Direct Student Loans (Direct Loans) Award Periods: July 1, 2022 through June 30, 2023; July 1, 2023 through June 30, 2024 Corrective Action Planned Annually, tests of access to Business Objects and properly authorized changes made to the logic within Business Objects specific to the disbursement report used by management will be conducted. Testing will be performed initially by Mayo Clinic’s internal audit team and in subsequent years by the Financial Aid Director and Director of Data Analytics. Persons Responsible for Corrective Action Anne Dahlen, Director of Student Financial Aid Aaron Pendl, Director of Data Analytics Target Completion Date November 30, 2024

View Audit 310163

Finding 402908 (2023-005)

Significant Deficiency 2023

Mayo Clinic

MN

Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.319 § 200.320

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Pass-Through Entity: The University of Texas Health (93.853, NS119834) Assistance Listing Nos.: 12.420, 93.310, 93.353, 93.393, an...

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Pass-Through Entity: The University of Texas Health (93.853, NS119834) Assistance Listing Nos.: 12.420, 93.310, 93.353, 93.393, and 93.853 Award Numbers: W81XWH-15-1-0292 (12.420), OD23121 (93.310), CA246568 (93.353), CA259201 (93.393), NS119834 (93.853), NS122096 (93.853) Award Periods: Various Corrective Action Planned Management conducted an education and training session for procurement teams in June 2024 to reinforce procurement requirements and documentation standards. Management will implement an independent sanction and debarment check for suppliers as part of existing quarterly audits over Supplier AP vendor master tables and related changes to those tables. Persons Responsible for Corrective Action Daniel Schmitz, Division Chair - Supply Chain Management Scott Hammer, Director - Supply Chain Management Target Completion Date June 30, 2024

View Audit 310163 Questioned Costs: $1

Finding 402906 (2023-004)

Material Weakness 2023

Mayo Clinic

MN

Allowable Costs / Cost Principles

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Pass-Through Entities: Boston University, Georgia Institute of Technology, Massachusetts General Hospital, NYU Grossman School of Medicine, Stanford University, The University of...

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Pass-Through Entities: Boston University, Georgia Institute of Technology, Massachusetts General Hospital, NYU Grossman School of Medicine, Stanford University, The University of Texas, University of Buffalo, University of Chicago, and Washington University Federal Cluster: Research and Development (R&D) Assistance Listing Nos.: 12.300, 12.420, 93.233, 93.273, 93.279, 93.310, 93.350, 93.393, 93.395, 93.396, 93.397, 93.837, 93.838, 93.846, 93.847, 93.853, 93.855, 93.859, 93.865, and 93.866 Award Numbers: Various Award Periods: Various Corrective Action Planned Management has made improvements to the salary cap application to ensure salaries are being correctly charged. The salary cap application is working effectively as of January 1, 2024. Persons Responsible for Corrective Action Susan Norby, Division Chair - Financial and Accounting Services, Research Finance Sarah Ward, Vice Chair - Financial and Accounting Services, Research Finance Target Completion Date January 31, 2024

View Audit 310163

Finding 402905 (2023-003)

Material Weakness 2023

Mayo Clinic

MN

Subrecipient Monitoring

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Assistance Listing Nos.: 12.RDC, 12.300, 93.393, 93.396, 93.847, 93.853, 93.859 Award Numbers: Various Award Periods: Various Co...

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Assistance Listing Nos.: 12.RDC, 12.300, 93.393, 93.396, 93.847, 93.853, 93.859 Award Numbers: Various Award Periods: Various Corrective Action Planned Monthly/quarterly reviews, including completion of subaward monitoring checklists, resumed in January 2024. Management's expectations have been communicated to those responsible for the control process regarding timely checklist completion and retention of documentation. Persons Responsible for Corrective Action Susan Norby, Division Chair - Financial and Accounting Services, Research Finance Sarah Ward, Vice Chair - Financial and Accounting Services, Research Finance Target Completion Date January 31, 2024

View Audit 310163

Corrective Action Plans

Filters