Corrective Action Plans

Finding 156 (2023-008)

Material Weakness 2023

VA

Eligibility Internal Control / Segregation of Duties

Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financia...

Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financial aid grant to the student's oustanding account balance as a condition of receipt of or eligibility for an emergency financial aid grant funding. The recipient also acknowledges that adding preconditions to receiving a financial aid grant that thwart this requirement may be subjected to oversight and corrective action. In consideration for this award, Recipients agree that they hold these grant funds in trust for students and act in the nature of a fiduciary for students. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. Now that the FY23 audit is finalized, any such compliance issues with students will be taken care of during actual registration process. In the future, any such forms that will need student authorization will be handled during the registration process. Responsbile Person(s): Robin Jefferson, Director of Student Accounts rljefferson@vuu.edu 804 342-3976. Robert Merino, Executive Director of Financial Aid jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 153 (2023-007)

Material Weakness 2023

Virginia Union University

VA

Reporting

Criteria: The CARES, CRRSAA, and ARP institutional quarterly portion of reporting requirements involve publicly posting completed forms on the Institution's website. The forms must be conspicuously posted on the Institution's primary website on the same page as the reports of the IHE's activities as...

Criteria: The CARES, CRRSAA, and ARP institutional quarterly portion of reporting requirements involve publicly posting completed forms on the Institution's website. The forms must be conspicuously posted on the Institution's primary website on the same page as the reports of the IHE's activities as to the emergency financial aid grants to students (Student Aid Portion) are posted. This information must also be updated no later than 10 days after the end of each calendar quarter (September 30, and December 31, March 31, and June 30). The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. The plan date for correction for this finding was December 31, 2023. Therefore, the plan was not realized due to the timing of completion of the FY22 audit. Now that the FY23 audit is completed, the Office of Sponsored Research & Innovation will designate a person to verify that reports are posted by periodically checking the website after request are made. Responsible Person(s): Linda Jackson, VP Sponsored Research & Innovation lrjackson@vuu.edu 804 257-5807. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 149 (2023-006)

Significant Deficiency 2023

Virginia Union University

VA

Questioned Costs Internal Control / Segregation of Duties

Criteria: The Institution must verify that the student with Verification code V4 or V5 has a high school completion status and has signed an Identity of education purpose statement. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: Individual ...

Criteria: The Institution must verify that the student with Verification code V4 or V5 has a high school completion status and has signed an Identity of education purpose statement. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: Individual files are being created and stored in a safe place during and after verification is completed. In addition, a digital copy is being placed in cloud storage. Responsible Person(s): Robert Merino, Executive Director jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218 Questioned Costs: $1

Finding 145 (2023-005)

Material Weakness 2023

Virginia Union University

VA

Criteria: Regulations require the Institution refunds calculated for students who withdrew during a semester be remitted to the Department of Education timely, within 45 days of withdrawal. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The...

Criteria: Regulations require the Institution refunds calculated for students who withdrew during a semester be remitted to the Department of Education timely, within 45 days of withdrawal. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. The plan date for correction for this finding was December 31, 2023. Therefore, the plan was not realized due to the timing of completion of the FY22 audit. Now that the FY23 audit is completed, the Registrar will put in polace the report that was created to identify students who completed the official withdrawal process. The Financial Aid Director will work with the Registrar to create an attendance report to identify students who unofficially withdraw. The report will be evaluated every week to meet the 14-day date of determination requirement. Responsbile Person(s): Doreen Dixon, Registrar ddixon@vuu.edu 804 257-5845. Robert Merino, Executive Director jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 141 (2023-004)

Significant Deficiency 2023

Virginia Union University

VA

Questioned Costs Internal Control / Segregation of Duties

Criteria: The Instituion must verify that the student remains eligible to receive financial aid prior to disbursements of funds. From appendix A of compliance supplment: Student must maintain good standing, or satisfactory academic progress (34CFRs668.16, 668.32(f), 668.34, 690.75, 675.9, 676.9, 685...

Criteria: The Instituion must verify that the student remains eligible to receive financial aid prior to disbursements of funds. From appendix A of compliance supplment: Student must maintain good standing, or satisfactory academic progress (34CFRs668.16, 668.32(f), 668.34, 690.75, 675.9, 676.9, 685.200, 686.11, 20 USC 1070h; 42 CFR 57.306; 42 USC 293a(d)(2)). Satisfactory academic progress (SAP) is defined as Maintenance of satisfactory progress (2.0 GPA). The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. The plan date for correction for this finding was December 31, 2023. Therefore, the plan was not realized due to the timing of completion of the FY22 audit. Now that the FY23 audit is completed, the Finanical Aid Team will print a report of communication sent to students who have lost their eligibility or are at risk of losing their eligibility at the end of each semester. The report will be placed in a secure location for documentation. Responsible Person(s): Robert Merino, Executive Director jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218 Questioned Costs: $1

Finding 137 (2023-003)

Significant Deficiency 2023

Virginia Union University

VA

Student Financial Aid Matching / Level of Effort / Earmarking

Criteria: Regulations require the Institution ensure exit counseling is conducted with each Direct Subsidized Loan or Direct Unsubsidized Loan borrower and graduate borrower shortly before the student borrower ceases at least half-time study. Exit counseling must be conducted within 30 days after th...

Criteria: Regulations require the Institution ensure exit counseling is conducted with each Direct Subsidized Loan or Direct Unsubsidized Loan borrower and graduate borrower shortly before the student borrower ceases at least half-time study. Exit counseling must be conducted within 30 days after the school learns the student borrower has withdrawn from school or failed to complete the exit counseling [34 CFR 685.304(b), (1) & 34 CFR 674.42(b)]. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. The plan date for correction for this finding was December 31, 2023. Therefore, the plan was not realized due to the timing of completion of the FY22 audit. Now that the FY23 audit is completed, the Registrar will email exit counseling materials as an attachment to the email or send a email containing URL or hyperlink which will take the student directly to the Exit Counseling page on StudentAid.gov. Responsbile Person(s): Doreen Dixon, Registrar ddixon@vuu.edu 804 257-5845. Robert Merino, Executive Director jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 133 (2023-002)

Significant Deficiency 2023

Virginia Union University

VA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Criteria: Under the Pell grant and ED loan programs, Institutions are responsbile for timely enrollment reporting to the NSLDS whether they report directly or via a third-party servicer such as the National Student Clearinghouse (NSC). Enrollment reporting in a timely and accurate manner is critical...

Criteria: Under the Pell grant and ED loan programs, Institutions are responsbile for timely enrollment reporting to the NSLDS whether they report directly or via a third-party servicer such as the National Student Clearinghouse (NSC). Enrollment reporting in a timely and accurate manner is critical for effective management of the programs. Enrollment information must be reported within 60 days whenever enrollment status changes for students unless a roster is submitted within 60 days. These changes include reductions or increases in attendance levels, withdrawals, graduations, or approved leave-of-absence. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. The plan date for correction for this finding was December 31, 2023. Therefore, the plan was not realized due to the timing of completion of the FY22 audit. Now that the FY23 audit is completed, the Registrar and Information Technology will ensure monthly reporting to the National Clearinghouse. In addition, the Registrar will determine the root cause is corrected and enrollment is reported correctly. These procedures will become part of the Registrar's Standard Operating Procedures. Responsbile Person(s): Doreen Dixon, Registrar ddixon@vuu.edu 804 257-5845. Kofi Jack, Chief Information Officer kjack@vuu.edu 804 257-5709. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 129 (2023-001)

Significant Deficiency 2023

Virginia Union University

VA

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

Criteria: Institutions are required to report all Direct Loan (DL) disbursements and submit required records to the Department of Education's Common Origination and Disbursement (COD) which is a web-based system for processing, storing and reconciling DL financial aid data. Each month, the COD provi...

Criteria: Institutions are required to report all Direct Loan (DL) disbursements and submit required records to the Department of Education's Common Origination and Disbursement (COD) which is a web-based system for processing, storing and reconciling DL financial aid data. Each month, the COD provides Institutions with a School Account Statement (SAS) date file which consists of a Cash Summary, Cash Detail and (optional at the request of the school) Loan Detail records. The school is required to reconcile these files to the Insitution's financial records ("DL Reconciliations"). While the University has made significant improvements in this reconciliation process and that of the other related federal award programs, there are still unreconciled differences in all three major federal pass-through program's reonciliations as noted in the financial statement audit. However, for FY23, these differences netted to an immaterial difference overall and were no adjusted / passed during the financial statement audit. However, differences still remain, and the reconciliation process still needs to be improved upon. The University concurs with the audit finding and will adhere to the corrective action plan. Corrective action: The Student Financial Aid activity was reconciled among the Registrar, Financial Aid, and Business Offices as of June 30, 2023, at detailed (student) level. Monthly reconciliations will be maintained effective July 2023. Responsible Person(s): Robert Merino, Executive Director of Financial Aid jrmerino@vuu.edu 218 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 127 (2023-002)

Significant Deficiency 2023

St. Ambrose University

IA

Student Financial Aid Reporting

The University did not timely disburse a Pell grant to an eligible student within the payment period. Corrective Actions Taken or Planned: Run the pending Pell Grant report weekly and investigate any returning corrections that were delayed by CPS such as this case. Anticipated Completion Date: Augu...

The University did not timely disburse a Pell grant to an eligible student within the payment period. Corrective Actions Taken or Planned: Run the pending Pell Grant report weekly and investigate any returning corrections that were delayed by CPS such as this case. Anticipated Completion Date: August 1, 2023 Contact Person: Julie Haack

View Audit 208

Finding 126 (2023-001)

Significant Deficiency 2023

St. Ambrose University

IA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The University did not accurately or timely report enrollment changes to the National Student Loan Data System (NSLDS). Corrective Actions Taken or Planned: Based on these circumstances of a reported status being overwritten by a monthly update, we will do a random audit of all reported withdrawn s...

The University did not accurately or timely report enrollment changes to the National Student Loan Data System (NSLDS). Corrective Actions Taken or Planned: Based on these circumstances of a reported status being overwritten by a monthly update, we will do a random audit of all reported withdrawn students to make sure the correct status has flowed through to NSLDS from NSLC Anticipated Completion Date: December 1, 2023 Contact Person: Julie Haack

View Audit 208

Finding 124 (2023-001)

Significant Deficiency 2023

Regional Food Bank of Oklahoma

OK

Procurement, Suspension & Debarment § 200.303

At the beginning of FY23, the following steps were initiated to ensure board review and approval of all contracts over an annual value of $500,000 per internal financial policy: - The CFO will flag all contracts in excess of the stated threshold and notify the CEO, Executive Assistant, and board Tr...

At the beginning of FY23, the following steps were initiated to ensure board review and approval of all contracts over an annual value of $500,000 per internal financial policy: - The CFO will flag all contracts in excess of the stated threshold and notify the CEO, Executive Assistant, and board Treasurer that an action of the board will be required. - A standing agenda item will be added for the board finance committee to discuss any notable contracts and potential board approval requirements at each meeting. To prevent the case in which a contract is overlooked due to multiple contracts requiring consideration at the same time, the organization will seek out an automated solution such as electronic workflows or contract lifecycle management software to be implemented in FY24 in combination with the previously established actions above.

View Audit 182

Finding 119 (2023-002)

Significant Deficiency 2023

Health Services, Inc.

AL

Special Tests & Provisions Eligibility Significant Deficiency

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining ...

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

View Audit 152

Finding 118 (2023-003)

None 2023

Foxhill Manor Cooperative, Inc.

IN

Management will coordinate with the auditors to schedule on-location testing of tenant files and any additional documentation not sent electronically.

View Audit 141

Finding 117 (2023-002)

None 2023

Foxhill Manor Cooperative, Inc.

IN

Questioned Costs

Management has paid back the excess management fees and has updated their calculation for future payments.

View Audit 141 Questioned Costs: $1

Finding 116 (2023-001)

None 2023

Foxhill Manor Cooperative, Inc.

IN

Questioned Costs Cash Management HUD Housing Programs

Management is appealing to HUD regarding the required deposit. Funds are not currently available to make the prior year required deposit.

View Audit 141 Questioned Costs: $1

Finding 99 (2023-001)

Material Weakness 2023

Housing Authority of the City of Cheyenne

WY

HUD Housing Programs Material Weakness Special Tests & Provisions

Finding 2023-001 The Authority agrees with finding 2023-001 • The Authority, due to increasing interest rates, purchased several CD’s with various banks in order to maximize returns. During this process Form HUD 51999 was unintentionally omitted. o The Authority will immediately begin working with ...

Finding 2023-001 The Authority agrees with finding 2023-001 • The Authority, due to increasing interest rates, purchased several CD’s with various banks in order to maximize returns. During this process Form HUD 51999 was unintentionally omitted. o The Authority will immediately begin working with financial institutions that have Housing Choice Voucher or Public Housing finds on getting Form HUD 51999 completed. By December 31, 2023 the Authority will create an investment policy that outlines the requirements. Upon annual renewal of any investment the HUD website will be checked for updated forms.

View Audit 113

Finding 87 (2023-001)

Significant Deficiency 2023

The Friendly House of Davenport, Iowa

IA

Subrecipient Monitoring

The Organization has implemented a facility monitoring program that incorporates all of the facility visit requirements as described in the grant agreement.

View Audit 105

Finding 86 (2023-001)

Material Weakness 2023

Creative Housing Iv, Inc.

AR

HUD Housing Programs Special Tests & Provisions Cash Management

Contact Name: Barbara Staggs, CFO Contact Phone Number: 870-863-8194 Audit Period Ending: June 30, 2023 Audit Firm: FORVIS, LLP Federal Program: Supportive Housing for the Elderly, Assistance Listing No. 14.157 Federal Agency: U.S. Department of Housing and Urban Development September 12, 2023 Find...

Contact Name: Barbara Staggs, CFO Contact Phone Number: 870-863-8194 Audit Period Ending: June 30, 2023 Audit Firm: FORVIS, LLP Federal Program: Supportive Housing for the Elderly, Assistance Listing No. 14.157 Federal Agency: U.S. Department of Housing and Urban Development September 12, 2023 Finding 2023-001: Summary of Finding: The Project is required to calculate surplus cash at the end of each fiscal year and any amount greater than zero is required to be deposited to a federally insured residual receipts account within 60 days of year-end. The Project properly calculated surplus cash for fiscal year 2021; however, funds were not deposited into the residual receipts account as of 6/30/2023. Management should create policies and procedures to identify and transfer surplus cash to the residual receipts account to ensure compliance with this requirement. Management’s Corrective Action Plan: Management concurs with the finding. In the 2022 audit, it was found that Creative Housing IV, Inc. failed to make the surplus cash deposit for program year 2021 of $1,508. The deposit was made on September 7, 2023. Anticipated Completion Date: Completed

View Audit 101

Finding 79 (2023-001)

None 2023

Olive Avenue Apartments, Inc.

CA

HUD Housing Programs Reporting

Funds were needed for temporary cash flow shortage and the funds were returned on 7/18/2023.

View Audit 87

Finding 70 (2023-002)

Significant Deficiency 2023

Freestore Foodbank, Inc. and Affiliates

OH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to...

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to actively participate in a religious practice. To ensure compliance with this requirement, Freestore Foodbank Inc. and Affiliates require all local distributors receiving commodities to sign a local distributor agreement. Condition: CSH noted two instances (in a sample of 40 local distributor agreements) where food was distributed to religious organizations that do not abide by 45 CFR 260.34. Planned Corrective Action: In one instance, management issued food to an agency which had an expired local distributor agreement. Going forward, controls will be put in place by 9/30/23 to better track agency agreements to ensure all agencies receiving food have up-to-date agreements. The second instance involved the request for TANF food to be distributed to an organization who was not participating in the program. While the organization was correctly set up in our database, food was requested to be distributed. Management will improve training for staff and run periodic reports to ensure food is going to the proper organizations. Management will also set up periodic compliance meetings with program managers to develop best practices for each of the grants by 10/31/23.

View Audit 63

Finding 69 (2023-001)

Significant Deficiency 2023

Freestore Foodbank, Inc. and Affiliates

OH

Eligibility Internal Control / Segregation of Duties

Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, se...

Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, services or “assistance”. The child must be less than 18 years old, or, if a full-time student in a secondary school (or the equivalent level of vocational or technical training), less than 19 years old. Freestore Foodbank Inc. and Affiliates require all individuals receiving food to complete an eligibility form prior to receiving food. Condition: We noted one instance (in a sample of 40 clients) in which an eligibility form was not obtained prior to client receiving food. Planned Corrective Action: Management will perform periodic audits of eligibility forms starting 10/15/2023 to ensure compliance. Management will retrain staff to ensure completeness of the intake process. Furthermore, by 9/30/2023, management will work with the developers of the database to see if controls can be implemented in the software, so food cannot be distributed before the signing of the required form.

View Audit 63

Finding 67 (2023-001)

Significant Deficiency 2023

Clackamas County Childrens Commission

OR

Allowable Costs / Cost Principles

Corrective Action: The error identified related to a recurring accounts payable invoice template that is available to, and pending in, future accounting periods and posted monthly. The recurring invoice template was not updated at the time the distribution code was changed for current allocation ra...

Corrective Action: The error identified related to a recurring accounts payable invoice template that is available to, and pending in, future accounting periods and posted monthly. The recurring invoice template was not updated at the time the distribution code was changed for current allocation rates. The template has since been updated. We will continue to review the transactions prior to posting in the accounting system to correct any errors. Anticipated Completion Date: August 2023

View Audit 62

Finding 1 (2023-003)

Significant Deficiency 2023

Menominee Housing Commission

MI

Procurement, Suspension & Debarment

Management will implement policies and procedures to ensure the Commission is in compliance with all grant requirements pertaining to the Public Housing Capital Grant.

View Audit 14

Finding 1211144 (2022-005)

Material Weakness 2022

Carestl Health

MO

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.328 § 200.329

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.

View Audit 400353

Finding 1211143 (2022-004)

Material Weakness 2022

Carestl Health

MO

Cash Management Internal Control / Segregation of Duties § 200.305

We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to e...

We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to ensure funds are drawn and disbursed promptly ▪ Develop and enforce policies consistent with the Prompt Payment Act, including defined payment timelines ▪ Perform periodic reviews of cash flow and payment cycles to ensure compliance ▪ Assign oversight responsibility to ensure timely processing and documentation of payments Strengthening cash management practices will improve compliance with federal requirements and enhance overall financial control.

View Audit 400353

Corrective Action Plans

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