Corrective Action Plans

Finding 390096 (2023-004)

Material Weakness 2023

Early Childhood Learning Center of Greene County

NY

Reporting

ECLC did request copies of the submitted financial report SF 425 from HHS and to date have not received a response. Effective immediately, the Fiscal Specialist will retain copies of the supporting submission dates in the future, if reports should need to be filed.

View Audit 300988

Finding 390092 (2023-003)

Material Weakness 2023

Early Childhood Learning Center of Greene County

NY

Reporting § 200.512

ECLC is down to 2 employees consisting of the Executive Director and fiscal specialists. ECLC CFO resigned in April of 2022 and ECLC has not been able to fill that position since that time. UHY consultants have been obtained March 24, 2023 and they are helping with the fiscal process. The effect of ...

ECLC is down to 2 employees consisting of the Executive Director and fiscal specialists. ECLC CFO resigned in April of 2022 and ECLC has not been able to fill that position since that time. UHY consultants have been obtained March 24, 2023 and they are helping with the fiscal process. The effect of operating without a CFO has caused delays in preparing financials. ECLC has relinquished the Head Start Grant effective June 30, 2023, and is in the process of dissolution.

View Audit 300988

Finding 390090 (2023-002)

Significant Deficiency 2023

Israel Senior Citizens Housing Development Fund CORP

NY

The condition noted was due to improper set up of the general ledger system in which automatic journal entries were generated that incorrectly posted cash receipts as deferred income creating difficulty in reconciling tenant receivable balances. We are collaborating with a third-party consultant to...

The condition noted was due to improper set up of the general ledger system in which automatic journal entries were generated that incorrectly posted cash receipts as deferred income creating difficulty in reconciling tenant receivable balances. We are collaborating with a third-party consultant to correct this issue and will have the condition corrected by June 30, 2024.

View Audit 300975

Finding 390087 (2023-001)

Significant Deficiency 2023

University of Arkansas for Medical Sciences

AR

Reporting Internal Control / Segregation of Duties

Corrective Action Plan Finding 2023-001 Due to the prior year finding, management set a goal to ensure reporting deadlines are met by hiring an additional grants accounting staff member dedicated to monitor the head start program regulations and ensure reports are completed and filed timely. Grants...

Corrective Action Plan Finding 2023-001 Due to the prior year finding, management set a goal to ensure reporting deadlines are met by hiring an additional grants accounting staff member dedicated to monitor the head start program regulations and ensure reports are completed and filed timely. Grants accounting staff planned to utilize checklist functionality in the new financial system that will send required task notifications prior to reporting due dates to assist in meeting reporting deadlines. A new staff member was hired in July 2023. The responsibilities of the new staff member required several months of training and additional time to reconcile the head start accounts causing the January 30, 2023, report to be filed 3 days late. New processes have been implemented where the staff member assigned to the head start program meets weekly with the head start finance manager and director to discuss expenses allocated to the grants, assign tasks to be complete each week, and discuss reporting needs and deadlines. The new implemented processes have proven to assist in proper oversight and accurate financial management of the grants and allowed us to meet the last reporting deadline in November 2023. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: Implemented

View Audit 300960

Finding 390084 (2023-004)

Significant Deficiency 2023

Aims College District

CO

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

Condition: We identified one instance where a student’s program enrollment effective date did not match the institution’s records. Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party se...

Condition: We identified one instance where a student’s program enrollment effective date did not match the institution’s records. Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The College will review enrollment reporting procedures to determine where additional review of data and monitoring of third-party servicer data can be implemented to ensure accurate reporting. Name(s) of the contract person(s) responsible for corrective action: Chris Peterson – Director of Student Financial Aid, Stacy Sharp – Director of Registration and Records, and Laura Beyers – Director of Registration and Records Planned completion date for corrective action plan: June 30, 2024

View Audit 300954

Finding 390080 (2023-003)

Significant Deficiency 2023

Aims College District

CO

Student Financial Aid

Condition: The College did not maintain required Tier One servicer information on their website and did not disclose the URL to the Department of Education. Recommendation: We recommend the College implement procedures to identify requirements about disclosures when using third-party servicers and t...

Condition: The College did not maintain required Tier One servicer information on their website and did not disclose the URL to the Department of Education. Recommendation: We recommend the College implement procedures to identify requirements about disclosures when using third-party servicers and to implement such requirements on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The College has updated the student refund webpage to include the contract maintained with the Tier One servicer and will disclose the URL to the Department of Education. The College will adjust internal review procedures to ensure disclosure requirements are identified and implemented. Name(s) of the contract person(s) responsible for corrective action: Kailey Block – Controller and Jennifer Gilsdorf – Assistant Controller Planned completion date for corrective action plan: May 1, 2024

View Audit 300954

Finding 390079 (2023-001)

Significant Deficiency 2023

Quinsigamond Community College

MA

Questioned Costs Student Financial Aid

Corrective Action Plan The Student Financial Services department has undergone process improvements over the previous fifteen months. The processes and procedures for the calculation and Return of Title IV funds have been reviewed and staff in charge of these functions have been trained. Effective f...

Corrective Action Plan The Student Financial Services department has undergone process improvements over the previous fifteen months. The processes and procedures for the calculation and Return of Title IV funds have been reviewed and staff in charge of these functions have been trained. Effective for the Fall semester of FY24, rather than just a sampling, every calculation has been, and continues to be, double checked by another staff member who does recalculations before the revised award letter is sent and funds returned. Management is also in the process of implementing a change in staff areas of responsibility and will be moving the individual whose errors have been most frequent to administer another, less complex process. Timeline for Implementation of Corrective Action Plan The corrective action plan was implemented as of October 1, 2023. Contact Person Karen Grant, Financial Aid Director

View Audit 300952 Questioned Costs: $1

Finding 390069 (2023-004)

Material Weakness 2023

Gulf Coast Jewish Family and Community Services, INC

FL

Questioned Costs Reporting Material Weakness § 200.502 § 200.510

Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and impleme...

Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and implement internal controls around the Schedule reconciliation process back to the consolidated financial statements. The corrective action will be implemented no later than June 30, 2024. The primary designated official is Chief Financial Officer.

View Audit 300946 Questioned Costs: $1

Finding 390068 (2023-001)

Significant Deficiency 2023

Hospital Sisters Health System

IL

Questioned Costs Allowable Costs / Cost Principles § 200.430

Finding #2023-001: Reconciliation of Allocated Costs CLIENT PLANNED ACTION: Hospital Sisters Health System agrees with the finding and will reevaluate the procedures in place to reconcile all costs allocated to grants. We will implement processes to ensure that all costs are substantiated with ap...

Finding #2023-001: Reconciliation of Allocated Costs CLIENT PLANNED ACTION: Hospital Sisters Health System agrees with the finding and will reevaluate the procedures in place to reconcile all costs allocated to grants. We will implement processes to ensure that all costs are substantiated with appropriate supporting detail and are reconciled and reviewed in a timely manner. CLIENT RESPONSIBLE PARTY: Steve Canny, System Director-Financial Reporting, Compliance & Internal Control COMPLETION DATE: We anticipate having these procedures in place by June 30, 2024.

View Audit 300930 Questioned Costs: $1

Finding 390065 (2023-002)

Significant Deficiency 2023

Vermont Law and Graduate School, Inc. and Subsidiary

VT

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The School will work with its University Accounting Services (UAS) representative to obtain the UAS compliance examination report on a timely basis each year. If UAS is unable to provide the compliance examination report on a timely basis, the School will consider finding another vendor to assist wi...

The School will work with its University Accounting Services (UAS) representative to obtain the UAS compliance examination report on a timely basis each year. If UAS is unable to provide the compliance examination report on a timely basis, the School will consider finding another vendor to assist with the billings, collections and due diligence for the Federal Perkins Loan Program. Responsible Parties: Nathaniel Hibler – Vice President of Finance (802) 831-1204 Emily Parker – General Ledger Accountant (802) 831-1271 Estimated Completion Date: June 30, 2024

View Audit 300926

Finding 390062 (2023-001)

Significant Deficiency 2023

Vermont Law and Graduate School, Inc. and Subsidiary

VT

Student Financial Aid Matching / Level of Effort / Earmarking

The Registrar’s office of Vermont Law and Graduate School (the School) will continue to run monthly enrollment reports and upload them into the Clearinghouse through their website. Any anomalies or glitches discovered by the Registrar’s Office will be discussed with the Information Technology depar...

The Registrar’s office of Vermont Law and Graduate School (the School) will continue to run monthly enrollment reports and upload them into the Clearinghouse through their website. Any anomalies or glitches discovered by the Registrar’s Office will be discussed with the Information Technology department who will contact the software manufacturer (Jenzabar). If a patch is deemed necessary, it will be installed through an update by the Software Manufacturer and Information Technology. Responsible Parties: Maureen Moriarty – Registrar (802) 831-1235 Melissa Erickson – Director, Financial Aid (802) 831-1235 Estimated Completion Date: June 30, 2024

View Audit 300926

Finding 390061 (2023-003)

Material Weakness 2023

Ohio Medical Transportation, Inc. D/b/a Medflight of Ohio

OH

Material Weakness Reporting Matching / Level of Effort / Earmarking

Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and ...

Finding Number: 2023-003 Condition: The Corporation reported the incorrect amount of lost revenues for the period 4 portal submission for MedFlight. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure data uploaded into the portal agrees to underlying supporting documentation. Contact person responsible for corrective action: Joe Abel, Chief Financial Officer Anticipated Completion Date: 4/30/2023

View Audit 300923

Finding 390058 (2023-001)

Significant Deficiency 2023

Williams Unified School District No. 2

AZ

Reporting Significant Deficiency

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: March 25, 2024 Planned Corrective Action: The District will monitor and ensure amounts expended a...

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: March 25, 2024 Planned Corrective Action: The District will monitor and ensure amounts expended and reported from the ESSER I, II, & III grants agree to the District's accounting records. The Business Manager and Federal Programs Director will work hand in hand to ensure expended funds are reported accurately.

View Audit 300917

Finding 390056 (2023-002)

Material Weakness 2023

Burlingame School District

CA

Questioned Costs

The District agrees with the recommendation and has started the process of revising the claims filed.

View Audit 300912 Questioned Costs: $1

Finding 390055 (2023-001)

None 2023

City of Willows

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Program Income

We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Co...

We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: Given the strain on resource available among City staff, the City is working to hire an outside consulting firm to assure a consisten loan monitoring program is in place. Anticipated Completion Date: June 2024

View Audit 300908

Finding 390054 (2023-002)

None 2023

City of Willows

CA

Subrecipient Monitoring Program Income

We recommend that the City develop procedures to ensure that the CDBG Annual Performance Report is filed by the required due date. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: The City has recently brought on ...

We recommend that the City develop procedures to ensure that the CDBG Annual Performance Report is filed by the required due date. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: The City has recently brought on staff to complete the periodic reports required by HCD. It is the intent of the City to have this finding resolved by the end of FY 2023-24. Anticipated Completion Date: June 2024.

View Audit 300908

Finding 390051 (2023-001)

Significant Deficiency 2023

Portland State University

OR

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Recommendation: We recommend that the University implement processes and/or internal controls that ensure that a student has completed entrance counseling prior to disbursing Direct Loans proceeds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Recommendation: We recommend that the University implement processes and/or internal controls that ensure that a student has completed entrance counseling prior to disbursing Direct Loans proceeds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The error was caused by an abrupt resignation of loan processing staff and a lack of redundancy in critical processing areas. A staff member who was new to loan administration originated a loan then disbursed it to the student the moment it returned from COD. This rapid processing was in response to the student’s dire need for housing funding; however, the expedited process inadvertently circumvented the Banner system’s safeguards. This previously unknown issue has been resolved with the following systems updates: 1. Improved training and documentation 2. The previous system relied on RRAAREQ to prevent disbursement; however, the new system has a secondary and tertiary check that prevents disbursement. Both the entrance counseling tick box on RLADLOR and a positive indicator on the table that captures raw entrance counseling data (RPILECS) must align for a loan disbursement. Name of the contact person responsible for corrective action: Elijah Herr, Director of Financial Aid Planned completion date for corrective action plan: March 2024

View Audit 300906 Questioned Costs: $1

Finding 390049 (2023-002)

Significant Deficiency 2023

Portland State University

OR

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates reported to NSLDS agree to the enrollment effective dates per the University’s records. Explanation of disagreement with audi...

Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates reported to NSLDS agree to the enrollment effective dates per the University’s records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: It appears that the erroneous enrollment status effective date reported is equal to the certification date for the enrollment file that was sent to the National Student Clearinghouse (NSC). We are researching how the certification date may have been substituted as the enrollment status effective date. Name of the contact person responsible for corrective action: Nicolle DuPont, Associate Registrar Planned completion date for corrective action plan: April 2024

View Audit 300906

Finding 390048 (2023-003)

Significant Deficiency 2023

Portland State University

OR

Student Financial Aid Subrecipient Monitoring Internal Control / Segregation of Duties

Recommendation: We recommend that the University strengthen its internal controls over monitoring the academic engagement for students that are enrolled in distance education courses at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...

Recommendation: We recommend that the University strengthen its internal controls over monitoring the academic engagement for students that are enrolled in distance education courses at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The University had already identified this weakness prior to the Single Audit. To address this weakness, Portland State University has implemented a robust Initiation of Attendance protocol that is required of every instructor. Faculty were informed of: 1) Federal regulations related to initiation of attendance. 2) The standards used for documenting academic engagement in an online environment. 3) The method by which the instructor positively indicates that an online student has academically engaged in the course. The University has provided written policies on its website and engaged in a vigorous communication plan with both faculty and students. Compliance with the new policy is monitored through weekly reporting, and instructors who have not documented the initiation of attendance are referred to their dean, chair or department head. Prior to any reduction in Title IV aid, students are notified of any missing documentation and encouraged to speak with their instructors immediately. Last, reconciliation reports are monitored by the financial aid office for discrepancies and any conflicting information is resolved by contacting the instructor. Name of the contact person responsible for corrective action: Elijah Herr, Director of Student Financial Aid, Cindy Baccar, Associate Vice Provost & University Registrar and Karenna Wait, Director of Enterprise Applications. Planned completion date for corrective action plan: September 2023

View Audit 300906

Finding 390042 (2023-002)

Significant Deficiency 2023

Ballad Health

TN

Reporting § 200.303 § 200.502 § 200.510

Ballad Health will utilize technology efficiencies within upgraded accounting system to supplement reporting. Additionally, a resource will be added directly responsible for grant accounting. The SEFA will also be reviewed frequently to ensure accuracy.

View Audit 300905

Finding 389997 (2023-002)

Significant Deficiency 2023

Washington County Commission on Aging, Inc.

MD

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the proc...

NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the procedures involved in recording employee time on timesheets and transferring this data to the financial management system. The CFO will immediately evaluate the need for additional controls to ensure accurate recording of time charged to programs as reflected on the employee's timesheet. The CFO will immediately implement new processes that establish checks and balances to verify that the programs charged in the general ledger align with the time recorded by the employees and is verified by their supervisor. The CFO and HR director will provide training sessions to all staff and new hires on the importance of accurately capturing and recording payroll costs by April 30, 2024. The CEO will immediately provide training to the CFO and staff accountant on the significance of aligning time charged with the programs designated in the general ledger for proper grant award billing. The CFO will conduct periodic reviews of payroll transactions to identify any discrepancies or irregularities promptly and take action immediately upon identification of such. These reviews will continue through FY 2025.

View Audit 300903

Finding 389996 (2023-001)

None 2023

Washington County Commission on Aging, Inc.

MD

Reporting § 200.512

This incident is an anomaly due to the unanticipated loss of an employee in a small department. The root cause is lack of human capital in the department responsible for the submission of the audit to the Federal Audit Clearinghouse. We acknowledge the importance of adhering to regulatory deadlines ...

This incident is an anomaly due to the unanticipated loss of an employee in a small department. The root cause is lack of human capital in the department responsible for the submission of the audit to the Federal Audit Clearinghouse. We acknowledge the importance of adhering to regulatory deadlines and ensuring the timely submission of these documents. In response to your recommendation, we have already implemented measures to streamline our reporting processes and enhance our internal communication channels to facilitate the timely completion and submission of the required documents. This has involved establishing clear timelines, assigning responsibilities to designated personnel, and implementing monitoring mechanisms to assure that we meet the submission deadlines. The Chief Financial Officer (CFO) was responsible for the submission of the single audit on or before the March 31, 2024 deadline. This will be completed on or before March 31, 2024. The CEO will request board of directors' approval to hire an Executive Finance Officer (EFO) in an effort to increase the depth of the finance department. This will provide coverage during unexpected absenses in an effort to avoid future delays. The board of directors' approved the posting of a new EFO position on September 15, 2023. Position is posted and will remain posted until the position is filled. As soon as the EFO is hired, the CFO and EFO will cross train all duties related to the timely completion of documents to assure the timely submission of the single audit and assure that the Federal Audit Clearinghouse deadline is met. This is pending the hiring of the EFO. The position is currently posted. By October of each year, the CFO or EFO will conduct random sample internal audits or reviews before the single audit submission deadline to ensure documents are accurate and in compliance with federal regulations. Implement plans of correction for any areas identified out of compliance. This process is on-going.

View Audit 300903

Finding 389992 (2023-002)

None 2023

Queens University of Charlotte

NC

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

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the student for...

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the student for both the fall 2022 and spring 2023 semesters. We can document the spring 2023 loan disbursement notification was sent but are unable to document the date. Our internal processes dictate that the notification would normally be sent on the date of disbursement. We will develop and implement additional controls to effectively capture a student’s disbursement notification to ensure that both a record of the notification and the date are maintained. Anticipated Completion Date: August 15, 2024

View Audit 300901

Finding 389991 (2023-005)

None 2023

Queens University of Charlotte

NC

Student Financial Aid Period of Performance Reporting

Individual Responsible for Corrective Action: Linda Fleischman, Registrar Corrective Action: The Registrar’s Office will reach out to Jenzabar to determine what is triggering the incorrect program start date. Beginning with the summer 2024 students, each new student record will be reviewed prior to...

Individual Responsible for Corrective Action: Linda Fleischman, Registrar Corrective Action: The Registrar’s Office will reach out to Jenzabar to determine what is triggering the incorrect program start date. Beginning with the summer 2024 students, each new student record will be reviewed prior to the initial National Student Clearinghouse submission to ensure that the start date is being reported correctly. Anticipated Completion Date: August 15, 2024

View Audit 300901

Finding 389987 (2023-001)

None 2023

Queens University of Charlotte

NC

Cash Management

Individual Responsible for Corrective Action: Don Barton, Controller Corrective Action: Cash management of Title IV funds at the University is generally performed only on a reimbursement basis. In this situation there was a one-time error in calculating available FWS funds and year-to-date FWS ear...

Individual Responsible for Corrective Action: Don Barton, Controller Corrective Action: Cash management of Title IV funds at the University is generally performed only on a reimbursement basis. In this situation there was a one-time error in calculating available FWS funds and year-to-date FWS earnings such that approximately $11,000 in excess cash was received near the end of the 21-22 year and then carried forward. The error was discovered early in 22-23 but by that point earnings had outpaced cash on hand and so no effort was made to return funds. A new procedure with a multi-year workbook has been established for monitoring FWS earnings across award periods to prevent a repeat occurrence. Anticipated Completion Date: August 15, 2024

View Audit 300901

Corrective Action Plans

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