Corrective Action Plans

Finding 524425 (2024-001)

Significant Deficiency 2024

Morehouse College

GA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding No. 2024-001 SFA – Enrollment Reporting Federal Program Student Financial Assistance Cluster AL No. 84.268 Federal Direct Student Loans Federal Agency U.S. Department of Education Federal Award Years October 1, 2022 to September 30, 2023 October 1, 2023 to September 30, 2024 Criteri...

Finding No. 2024-001 SFA – Enrollment Reporting Federal Program Student Financial Assistance Cluster AL No. 84.268 Federal Direct Student Loans Federal Agency U.S. Department of Education Federal Award Years October 1, 2022 to September 30, 2023 October 1, 2023 to September 30, 2024 Criteria or Requirement Institutions are required to report enrollment information under the Pell grant and the Direct and FFEL loan programs via the NSLDS (OMB No. 1845-0035) (Pell, 34CFR 690.83(b)(2); FFEL, 34CFR 682.610; Direct Loan, 34 CFR 685.309; Perkins 34 CFR 674.19(f)). Condition and Context During our test work, we selected a sample of 40 students that had enrollment status changes during fiscal year 2024. Within our sample, we identified 3 instances where the students’ enrollment status was not properly communicated to National Student Loan Data System (NSLDS). These instances involved students who reported their status changes to the College after the normal reporting period had ended. Cause and Potential Effect Noncompliance due to no control in place to identify late submissions of status changes and ensure that these changes are properly communicated to the NSLDS. This lack of control could result in inaccurate or delayed reporting of student status changes to the NSLDS, potentially affecting loan servicing and compliance with federal regulations. Questioned Cost There were no questioned cost associated with the finding. Corrective Action Plan to Finding 2024-001: Contact person for corrective action: LaKeidra Gilford – Interim Registrar Office of Records and Registration Corrective Action Plan: Morehouse College plan to implement the following to address finding No. 2024-001. • Office of Records and Registration will create a new policy effective July 1, 2025, that will state any medical withdrawals received after the last day of the current term will not be honored. • Office of Records and Registration effective May 2025 will continue the current process with additionally submitting two (2) additional graduation reports each month after the initial report is sent to National Student Clearinghouse to ensure all graduates are captured and reported.

View Audit 343696

Finding 524423 (2024-005)

Material Weakness 2024

Isd # 682 Roseau

MN

Special Tests & Provisions

2024-005 FINDING Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures to ensure all transactions that qualify for wage rate requirements are identified to ensure compliance. Completion Date – March 31, 2025

View Audit 343693

Finding 524419 (2024-004)

Material Weakness 2024

Isd # 682 Roseau

MN

School Nutrition Programs Cash Management Eligibility

2024-004 FINDING Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures to ensure all students who receive a free or reduced meal have a current and accurate application on file. Completion Date – March 31, 2025

View Audit 343693

Finding 524415 (2024-003)

Material Weakness 2024

Isd # 682 Roseau

MN

School Nutrition Programs Special Tests & Provisions Eligibility

2024-003 FINDING Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures for verifying free and reduced applications. Completion Date – March 31, 2025

View Audit 343693

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

The prior year finding noted non-compliance with the Gramm-Leach Bliley Act. As a result, a consultant was hired in February 2024 to address 17 items required under the act. This plan was approved the US Department of Education with specific timelines and actions. The below gives an update on eac...

The prior year finding noted non-compliance with the Gramm-Leach Bliley Act. As a result, a consultant was hired in February 2024 to address 17 items required under the act. This plan was approved the US Department of Education with specific timelines and actions. The below gives an update on each required element. Due to issues with the main server, the risk assessment and monitoring software implementation was delayed.

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

1. Designation of a qualified individual to oversee the compliance with the Gramm-Leach Bliley Act. – Completed

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

2. Risk assessment 16 CFR 314.4(b) – Assessment completed. Installation of monitoring software is pending with expected completion by August 31, 2025

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

3. Access control 16 CFR 314.4(c)(1) – Completed

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

4. Identification 16 CFR 314.4(c)(2) – Partially completed pending installation of monitoring software

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

5. Encryption 16 CFR314.4(c)(3) – Open with estimated completion date of March 31, 2025

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Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

6. Encryption 16 CFR314.4(c)(5) – Open with estimated completion date of July 31, 2025

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

7. Multi-factor authentication 16 CFR314.4(c)(5) – Completed

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

8. Data retention 16 CFR314.4(c)(6) – Completed with a planned reevaluation of the policy

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

9. Change management 16CFR314.4(c)(7) – In progress

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

10. User logging 16CFR314.4(c)(8) - In progress

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Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

11. Security assessment 16CFR314.4(d)(1) – Open with estimated completion date of June 30, 2025

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

12. Monitoring software 16CFR314.4(d)(2) – Installation of monitoring software in pending

View Audit 343677

Finding 524411 (2024-001)

Significant Deficiency 2024

Boricua College, Inc.

NY

13 - 17. Continuing security program requirements 16CFR314.4 to 16CFR314.4(e-i) – Open with an estimated completion dates of March 2023 to August 31, 2025

View Audit 343677

Finding 524408 (2024-001)

Material Weakness 2024

Hardin County Regional Health Center, Inc.

TN

Procurement, Suspension & Debarment

In Finding 2024-001, a condition was noted in which the Organization did not obtain quotes or bids for an expenditure as required by the Organization’s procurement policy. Management recognizes the importance of complying with procurement policies. In response to Finding 2024-001, procedures will ...

In Finding 2024-001, a condition was noted in which the Organization did not obtain quotes or bids for an expenditure as required by the Organization’s procurement policy. Management recognizes the importance of complying with procurement policies. In response to Finding 2024-001, procedures will be implemented to ensure bids are obtained and properly documented in accordance with the Organization’s policy.

View Audit 343669

Finding 524405 (2024-003)

None 2024

Nome Community Center, Inc.

AK

Due to the nature of the cause of this finding, there is no other specific corrective action considered necessary. The Organization will ensure that future construction contracts, if any, contain any applicable prevailing wage requirement verbiage and certified payrolls will be received and reviewe...

Due to the nature of the cause of this finding, there is no other specific corrective action considered necessary. The Organization will ensure that future construction contracts, if any, contain any applicable prevailing wage requirement verbiage and certified payrolls will be received and reviewed.

View Audit 343642

Finding 524393 (2024-002)

Material Weakness 2024

Loma Linda University

CA

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs § 200.329

Finding 2024-002 – Internal control deficiency and noncompliance over Reporting related to performance reports Connecting Minority Communities Pilot Program – Timeliness and Accuracy During testing over the Reporting compliance requirement, management did not have effective internal controls in pl...

Finding 2024-002 – Internal control deficiency and noncompliance over Reporting related to performance reports Connecting Minority Communities Pilot Program – Timeliness and Accuracy During testing over the Reporting compliance requirement, management did not have effective internal controls in place to ensure performance reports were submitted by the deadline and completed correctly. Management did not submit the required performance reports by the deadline and certain key line items were not completed correctly. Management Response and Action Plan: Management will meet with the Principal Investigator and provide additional training emphasizing the importance of timely submission and accuracy of grant documentation and reports. In addition, management will monitor submission deadlines and follow-up with the Principal Investigator to ensure timely filing. Responsible Person: Executive Director of Sponsored Project Administration Target Date: February 2025

View Audit 343628

Finding 524392 (2024-001)

Material Weakness 2024

Loma Linda University

CA

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

Finding 2024-001 – Internal control deficiency and noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles related to payroll expenditures Connecting Minority Communities Pilot Program – Accuracy During testing over the Activities Allowed or Unallowed and Allowable C...

Finding 2024-001 – Internal control deficiency and noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles related to payroll expenditures Connecting Minority Communities Pilot Program – Accuracy During testing over the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirement, management did not have effective internal controls in place to ensure salaries, fringe benefits, and indirect costs were correctly allocated to the Federal award. Management Response and Action Plan: Management has adjusted for the incorrect allocation with the grantor (i.e., refunded the questioned costs) and will implement an additional review control of the allocation and final calculation of salaries, fringe benefits, and indirect costs. Responsible Person: Executive Director of Sponsored Project Administration Target Date: February 2025

View Audit 343628 Questioned Costs: $1

Finding 524391 (2024-003)

Significant Deficiency 2024

Kansas Health Science Center, Inc.

IL

Procurement, Suspension & Debarment § 200.303

Corrective Action Plan – Kansas Health Science University Identifying Number: 2024-003 Finding: Lack of Control Documentation over Review of Suspended/Debarred Vendors Applicable Regulation: Uniform Grant Guidance (2 CFR 180.300) states that when entering into a covered transaction with another ...

Corrective Action Plan – Kansas Health Science University Identifying Number: 2024-003 Finding: Lack of Control Documentation over Review of Suspended/Debarred Vendors Applicable Regulation: Uniform Grant Guidance (2 CFR 180.300) states that when entering into a covered transaction with another person at the next lower tier, the nonfederal entity must verify the person with whom the nonfederal entity intends to do business is not excluded or disqualified by: (a) checking Sam.gov Exclusions; or (b) collecting a certification from that person; or (c) adding a clause or condition to the covered transaction with that person. Finding: KHSU was not able to provide support showing that a check had been performed on vendors with whom KHSU entered into covered transactions to verify the vendor was not suspended or debarred. Corrective Action Taken or Planned: Effective immediately, the Chief Financial Officer (CFO) is responsible for reviewing and approving all new vendors. Additionally, the CFO has reviewed and verified that none of the vendors for FY24 were listed as suspended or debarred in the federal System for Award Management (SAM). Additionally, these measures will be put in place: 1. Implementation of Formal Documentation Process • Additional question added to required new vendor paperwork. Vendors must denote if they are currently suspended or debarred. • University procurement policy has been updated to include new process for vendor approvals. 2. Centralized Recordkeeping • All completed new vendor applications will continue to be maintained in a centralized and secure repository for auditing purposes (Workday). • CFO will maintain documentation on review of vendors, including date they were reviewed and if they are suspended or debarred. 3. Training and Communication • Updated internal processes have been communicated with staff involved in vendor management to ensure awareness. • Clear guidelines on the review, documentation, and recordkeeping processes has been distributed to relevant team members. 4. Periodic Monitoring and Quality Control • An internal review of vendor approvals will be conducted quarterly to ensure compliance with the updated policy. • The internal audit team will include the review of suspended/debarred vendor documentation as part of their regular audit procedures. Contact Person: Matt Ankenbrandt, Chief Financial Officer mankenbrandt@kansashsc.org Anticipated Completion Date: 2/1/25

View Audit 343627

Finding 524390 (2024-002)

Significant Deficiency 2024

Kansas Health Science Center, Inc.

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Corrective Action Plan – Kansas Health Science University Identifying Number: 2024-002 Finding: Improper Controls Over Personnel Expenses Applicable Regulation: Uniform Grant Guidance (2 CFR 200.430(g)(1)(i)) states charges to Federal awards for salaries and wages must be based on records that a...

Corrective Action Plan – Kansas Health Science University Identifying Number: 2024-002 Finding: Improper Controls Over Personnel Expenses Applicable Regulation: Uniform Grant Guidance (2 CFR 200.430(g)(1)(i)) states charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Finding: A KHSU supervisor did not properly document approval for one employee’s personnel activity reports. Corrective Action Taken or Planned: Upon being notified by the auditors of this specific issue, the organization took immediate steps to address the finding. The missing documentation for the personnel activity report was located and the supervisor provided retroactive written approval. The updated Personnel Activity Report was submitted to KDADS. This corrective action resolved the specific instance during the audit. In addition, the following will be implemented: 1. Development and Implementation of a Standard Operating Plan • A SOP for reviewing and documenting approvals of personnel activity reports (PARs) will be developed. • The procedure will include detailed steps for supervisors to review, approve, and retain documentation of PARs. 2. Training for Supervisors • All supervisors responsible for approving PARs will have one-on-one training on the new SOP by the Chief Financial Officer, emphasizing the importance of proper documentation to comply with internal controls and audit standards. • Training sessions will be scheduled. 3. Implementation of Monitoring Controls • A secondary review process will be introduced to ensure compliance with the new procedures, including review by the Principal Investigator. • The Grants Management Office or an equivalent oversight body will conduct periodic audits of PAR documentation to verify proper approvals. Contact Person: Matt Ankenbrandt, Chief Financial Officer mankenbrandt@kansashsc.org Anticipated Completion Date: 2/15/25

View Audit 343627

Finding 524389 (2024-001)

Significant Deficiency 2024

Kansas Health Science Center, Inc.

IL

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

Corrective Action Plan – Kansas Health Science University Identifying Number: 2024-001 Finding: Excess Cash – Student Financial Aid Applicable Regulation: According to Uniform Grant Guidance (34 CFR 668.166), the Secretary considers excess cash to be any amount of Title IV, HEA program funds, oth...

Corrective Action Plan – Kansas Health Science University Identifying Number: 2024-001 Finding: Excess Cash – Student Financial Aid Applicable Regulation: According to Uniform Grant Guidance (34 CFR 668.166), the Secretary considers excess cash to be any amount of Title IV, HEA program funds, other than Federal Perkins Loan program funds, that an institution does not disburse to students within the required timeframe. Institutions must return any amount of excess cash over the one-percent tolerance and any remaining cash after the seven-day tolerance period. Finding: Kansas Health Science University (KHSU) had excess cash for the Federal Direct Student Loan program, including $268,278 from July 12, 2023, to July 19, 2023, and amounts ranging from $2,204 to $13,385 from April 8, 2024, to April 23, 2024. For the first period, the excess cash exceeded the one-percent tolerance of prior year drawdowns and was not returned within the three business-day period. For the second period, although the excess cash did not exceed the one-percent tolerance, amounts were not returned within the seven-day period as required. Summary: KHSU identified two instances of excess cash due to delays in returning unused funds. The Funds were not returned to ED withing the required number of days, leading to a violation of the federal cash management requirements. The issue was related to an administrative oversight related to the timing of the return of drawn funds. Corrective Action Planned or Taken: 1. Procedure Update: KHSU will update its cash management procedures to ensure compliance with both the three-day and seven-day return requirements for excess cash. 2. Process Change: KHSU will implement a process to immediately review and reconcile drawdowns with disbursement needs. Drawdowns will be based strictly on reconciled disbursement schedules to prevent excess cash. 3. Internal Control Strengthening: Internal controls will be enhanced to include automated alerts for identifying excess cash and triggering prompt corrective actions. 4. Staff Training: Financial aid and accounting staff will undergo targeted training on Federal cash management regulations, focusing on the prevention and timely resolution of excess cash. 5. Improved Monitoring: KHSU will establish daily monitoring of cash balances during peak disbursement periods and periodic reviews to ensure ongoing compliance with Federal regulations. Contact Person: Theresa Cowan, Associate Vice President, Compliance and Student Finance tcowan@tcsedsystem.edu Anticipated Completion Date: December 16, 2024

View Audit 343627

Corrective Action Plans

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