Corrective Action Plans

Finding 520911 (2024-002)

Significant Deficiency 2024

WV

Cash Management Student Financial Aid Internal Control / Segregation of Duties

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University has formalized and documented financial processes to establish internal controls in order to ensure accurate, timely and consistent reporting. In addition, this has created a reasonable transition pla...

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University has formalized and documented financial processes to establish internal controls in order to ensure accurate, timely and consistent reporting. In addition, this has created a reasonable transition plan during employee turnover, as well as ensures proper and timely filings. The corrective action involves drawing down the funds from the G5 federal website and issuing refunds to students that day. There is a checks and balance process built in so multiple staff members are involved with the process. The financial aid department calculates the amount of a federal drawdown and relays that information to the business department. The senior accountant draws down the appropriate amount of federal financial aid. The student accounts billing coordinator applies the aid to the various student accounts in the software. After the aid has been applied, the student accounts billing coordinator determines if a refund is due to the students. Any students that are entitled to a refund will be cut a refund check that day. The students will then have a window of opportunity of to come pick up the refund checks. Within two business days, any students who have not picked up their refund checks will have them mailed to their address on file with the University. This process has been developed to ensure that students receive their refunds in a timely and accurate manner. Anticipated Completion Date: February 2024

View Audit 340797

Finding 520909 (2024-009)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Special Tests & Provisions Student Financial Aid

FINDING 2024-009 Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: Wheeling University worked with ECSI regarding Perkins information. With the Perkins program ending, we realized that we needed to move in the direction of closing out Perkins ...

FINDING 2024-009 Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: Wheeling University worked with ECSI regarding Perkins information. With the Perkins program ending, we realized that we needed to move in the direction of closing out Perkins files/information. The University is currently working with ECSI so that we are able to submit Perkins information/files to the Department of Education. We are gathering information (promissory notes, bankruptcy details, payment information, etc.) to assist ECSI with the process. Anticipated Completion Date: June 2025

View Audit 340797

Finding 520907 (2024-007)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Special Tests & Provisions Student Financial Aid

Name of Responsible Individual: Lori Kestner, Human Resources Generalist Corrective Action: The payroll Process for Federal Work Study: Student punches in on a computer or cell phone to log in and out when working at the start of their shift and the end of their shift. Timecards can be approved ...

Name of Responsible Individual: Lori Kestner, Human Resources Generalist Corrective Action: The payroll Process for Federal Work Study: Student punches in on a computer or cell phone to log in and out when working at the start of their shift and the end of their shift. Timecards can be approved by their supervisor/manager daily, weekly, or by the pay period which is every two weeks. The pay period ends on a Friday with the payroll processing to begin on the following Monday. On that Monday, all timecards must be corrected/updated and approved before they can be processed. Timecards with errors cannot be processed. Each Monday the supervisor/manager must log into the student timecard and "approve" the card for the pay period that ended on the past Friday. When the supervisor/manager opens the card on Monday it defaults to the current pay period and not the previous pay period that needs to be approved. The supervisor/manager must select the "previous" pay period in order to approve the card to be processed. In the case of the student in question, the supervisor/manager did not select the correct pay period and therefore approved the future timecard. As the payroll manager, I would have emailed him, the manager, that the card to be processed had not been approved. Upon that, he went back and approved the pay period that was to be processed. The approval on the next pay period that he mistakenly approved should have been removed. It was not. The process for card approvals is to check on the Monday of payroll the cards that are still in need of updates/corrections and approvals. A report is run and shows what cards our still without approval and with errors. The payroll manager communicates to the manager and the student that there are errors on the card and/or it still needs to be approved. Payment for that card cannot be made until errors are corrected and the card is approved. It is the supervisor and manager’s responsibility to ensure timecards are corrected and updated for processing. This error can be resolved with the supervisor/manager accountable for the accuracy of the time cards. Before processing a report, can be run by the payroll manager of the date/time of approval. All supervisors and managers who are responsible for the approval of timecards will be reeducated on the process and sign off that they understand their role. Those who do not adhere to the process will have additional training. As new supervisors and managers are hired, the process will be part of their on-boarding. Anticipated Completion Date: January 2025

View Audit 340797

Finding 520906 (2024-010)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Student Financial Aid Reporting

FINDING 2024-010 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges the FISAP report was filed with incorrect data and not amended in a timely manner. The University has developed a series of internal controls and procedures to ensure t...

FINDING 2024-010 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges the FISAP report was filed with incorrect data and not amended in a timely manner. The University has developed a series of internal controls and procedures to ensure that the data provided for the FISAP will be accurate going forward. All balance sheet accounts will be reconciled on a monthly basis and all revenue will be recorded on the ledger in the time period that it is earned. A monthly income statement and balance sheet will be generated to determine how much federal aid revenue has been reported throughout the year. The accounting software has a built-in process that will be run on a regular basis to make sure all entries are properly posted. This will ensure accurate reporting in the future. Anticipated Completion Date: June 2025

View Audit 340797

Finding 520905 (2024-006)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Internal Control / Segregation of Duties Special Tests & Provisions Student Financial Aid

Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: The University acknowledges that we were not in compliance during fiscal year 2024 with the federal guidelines to refund the student credit balances in a timely manner for the students in questio...

Name of Responsible Individual: Tracy Jenkins, Student Account Billing Coordinator Corrective Action: The University acknowledges that we were not in compliance during fiscal year 2024 with the federal guidelines to refund the student credit balances in a timely manner for the students in question. There was significant employee turnover at the University in the business office during fiscal year 2024 and training of new employees was ongoing at that time. This resulted in the delay in the student refunds within the sample selection that the auditors chose during fiscal year 2024. Since then the new and current staff members have been fully trained on their duties and responsibilities. Everyone involved has been informed of the student refund policies and requirements per the Title IV regulations. There have been procedures implemented to prevent this from being a repeat audit finding in the future. Anticipated Completion Date: July 2024

View Audit 340797

Finding 520904 (2024-005)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Questioned Costs Internal Control / Segregation of Duties Special Tests & Provisions

Name of Responsible Individual: Dylan J. Nowakowski, Director of Financial Aid Corrective Action: After Colleague was properly set up for Financial Aid for R2T4’s, the Director discovered that the calendars did not match the actual publicized academic calendar. Had the calendar been accurate with...

Name of Responsible Individual: Dylan J. Nowakowski, Director of Financial Aid Corrective Action: After Colleague was properly set up for Financial Aid for R2T4’s, the Director discovered that the calendars did not match the actual publicized academic calendar. Had the calendar been accurate with the correct dates of breaks of five days or more, then the R2T4 would have been accurate. The calendar in Colleague has now been corrected. For the years moving forward this will be verified before any R2T4 is calculated and submitted. All breaks that are five days or more are accurate. At Wheeling, we have a comprehensive R2T4 policy. This policy outlines how to count calendar days in a semester and provides clear instructions on what to do when a student withdraws during a break. Anticipated Completion Date: July 2024

View Audit 340797 Questioned Costs: $1

Finding 520903 (2024-012)

Material Weakness 2024

Wheeling Jesuit University INC

WV

Procurement, Suspension & Debarment

FINDING 2024-012 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the required procurement procedures and controls were not followed. The University is developing a series of internal controls and procedures to ensure that procur...

FINDING 2024-012 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the required procurement procedures and controls were not followed. The University is developing a series of internal controls and procedures to ensure that procurement procedures and internal controls are designed and followed as required for all NIH and NASA grant procurements. Anticipated Completion Date: June 2025

View Audit 340797

Finding 520902 (2024-011)

Material Weakness 2024

Wheeling Jesuit University INC

WV

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

FINDING 2024-011 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the records to substantiate the payroll costs were insufficient and lacking internal controls. Going forward the University plans to implement a strategic process ...

FINDING 2024-011 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the records to substantiate the payroll costs were insufficient and lacking internal controls. Going forward the University plans to implement a strategic process to document time and effort associated with research and development cluster and it’s federal grants. All employees that work with the Challenger Learning Center will continue to have their hours worked documented in the Paycom payroll software. Payroll is processed on a biweekly basis, and therefore on biweekly basis the payroll costs from the Challenger Learning Center will be reimbursed to the University from the various Challenger Learning Center bank accounts. This will be done as a percentage of time worked for the NIH Grant, the NASA Grant, and the general Challenger Learning Center functions. Anticipated Completion Date: June 2025

View Audit 340797 Questioned Costs: $1

Finding 520896 (2024-006)

Significant Deficiency 2024

East Orange Board of Education

NJ

Internal controls be enhanced to prevent cash overdrafts in the payroll Agency and Worker's Compensation bank accounts.

View Audit 340779

Finding 520894 (2024-001)

Significant Deficiency 2024

Bryant University

RI

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The University has taken the following steps to improve the accuracy and timeliness of enrollment reporting with respect to federal requirements. Summer withdrawals will now be reported directly to the National Student Clearinghouse (the Clearinghouse) as a service provider for transmissions of its ...

The University has taken the following steps to improve the accuracy and timeliness of enrollment reporting with respect to federal requirements. Summer withdrawals will now be reported directly to the National Student Clearinghouse (the Clearinghouse) as a service provider for transmissions of its enrollment reporting changes to the NSLDS at the time of withdrawal, ensuring timely and accurate reporting. The Registrar’s Office will submit a manual enrollment status change to the Clearinghouse. Since this audit finding was identified in the fall of 2024, the University had already reported all summer 2024 withdrawals during the first fall roster submission.

View Audit 340765

Finding 520890 (2024-001)

Significant Deficiency 2024

MacOupin County Public Health Department

IL

Special Tests & Provisions Internal Control / Segregation of Duties

Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" four (4) selections out of a sample size of forty (40) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, four (4) selections out of a ...

Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" four (4) selections out of a sample size of forty (40) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, four (4) selections out of a sample size of forty (40) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan: Management will ensure that all information is collected and input into the billing system correctly in order to avoid patients getting charged incorrect amounts for services. Antcipated Date of Completion: March 31, 2025. Name of Contact Person: Lori Sanson, CFO. Management's Response: Management is implementing weekly chart auditing of encounters from the prior week. These reviews will include a review of the client's financial information which includes assessment of the sliding fee scale paperwork completed, whether we have obtained proof of income, if the sliding fee was entered into the billing system, if the sliding fee adjustments are applied, if payment was collected, insurance information, and the client's balance. These audits will be sent to front office staff for corrections (if needed) or the CFO for review on a monthly basis. In addition, MCPHC Supervisors will obtain a monthly report of the clients that have not turned in proof of income in order to proactively reach out either by phone, email or mail and attempt to obtain the information.

View Audit 340762

Finding 520889 (2024-001)

Significant Deficiency 2024

Independence Place Cooperative of Willmar

MN

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 340755

Finding 520888 (2024-001)

Significant Deficiency 2024

Rainbow Fleet, Inc.

OK

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.512

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays e...

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays earlier in the audit process. Action Taken: Management agrees with the finding and will take steps to improve the timeliness of the audit process. Specifically, management has hired a new Chief Operating Officer and Chief Executive Officer who have been notified of the reporting requirements of the federal awards. Anticipated completion date: January 31, 2025 Name of contact person and title: Quisha Beardsley, Chief Executive Officer

View Audit 340750

Finding 520887 (2024-002)

Material Weakness 2024

Lutheran Social Services of Central Ohio Kensington Place, Inc.

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Condition: The Corporation did not deposit prior year surplus cash totaling $25,068 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact per...

Condition: The Corporation did not deposit prior year surplus cash totaling $25,068 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340745

Finding 520886 (2024-002)

Material Weakness 2024

Ashland Assisted Living, Inc. D/b/a Lutheran Village of Ashland

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Finding Number: 2024-002 Condition: The Corporation did not deposit prior year surplus cash totaling $56,345 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Acti...

Finding Number: 2024-002 Condition: The Corporation did not deposit prior year surplus cash totaling $56,345 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340744

Finding 520885 (2024-004)

Significant Deficiency 2024

Good Shepherd Real Estate Holding, LLC D/b/a the Good Shepherd

OH

HUD Housing Programs Reporting Significant Deficiency

Finding Number: 2024-004 Condition: The Corporation failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340743

Finding 520884 (2024-003)

Material Weakness 2024

Good Shepherd Real Estate Holding, LLC D/b/a the Good Shepherd

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Finding Number: 2024-003 Condition: The Corporation did not deposit prior year surplus cash totaling $19,794 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Acti...

Finding Number: 2024-003 Condition: The Corporation did not deposit prior year surplus cash totaling $19,794 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340743

Finding 520883 (2024-002)

Significant Deficiency 2024

Shawmet Homes, Inc.

MO

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

Recommendation: The Organization should review of its operating and maintenance policies and procedures, as well as review by the individuals monitoring the operating and maintenance of the property, to ensure that the necessary documentation showing that resident problems or concerns were responded...

Recommendation: The Organization should review of its operating and maintenance policies and procedures, as well as review by the individuals monitoring the operating and maintenance of the property, to ensure that the necessary documentation showing that resident problems or concerns were responded to in a timely manner is being completed. View of Responsible Officials and Corrective Actions: Shawmet Homes, Inc. has, and will continue to complete problems or concerns raised by tenants, and only failed to document timely completion within in our management system. The Organization has reviewed its staffing and implemented training, and periodic reviews of the work order system, to ensure that the documentation is being completed timely.

View Audit 340740

Finding 520881 (2024-001)

Significant Deficiency 2024

Youth Services Network, Inc.

IL

Internal Control / Segregation of Duties

Youth Services Network, Inc. has implemented several compensating controls but simply cannot justify the expense of hiring additional staff to reach the standard of segregation of duties suggested.

View Audit 340734

Finding 520877 (2024-002)

Material Weakness 2024

Vandalia Cusd 203

IL

Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Payroll disbursements will align to the approved salary schedule.

View Audit 340710

Finding 520867 (2024-003)

Material Weakness 2024

Vandalia Cusd 203

IL

Internal Control / Segregation of Duties Allowable Costs / Cost Principles School Nutrition Programs

Payroll disbursements will align to the approved salary schedule.

View Audit 340710

Finding 520865 (2024-004)

Significant Deficiency 2024

Linden-Kildare Consolidated Independent School District

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Due to the transition of personnel within the payroll and business office during the year, the District did not properly account for amounts that were previously requested under the grant as well as expense reversals that occurred near year-end. The District will take the recommendation of the audit...

Due to the transition of personnel within the payroll and business office during the year, the District did not properly account for amounts that were previously requested under the grant as well as expense reversals that occurred near year-end. The District will take the recommendation of the auditors and implement additional controls to monitor compliance with federal program guidelines.

View Audit 340692 Questioned Costs: $1

Finding 520857 (2024-002)

None 2024

Williams College

MA

Student Financial Aid Reporting Eligibility

Management agrees with the finding and in concurrence with the recommendations the Registrar’s Office processes and documentation will be updated as follows: Major change process: If a request is submitted to drop a major while a student is on leave, the effective date will be recorded as the date...

Management agrees with the finding and in concurrence with the recommendations the Registrar’s Office processes and documentation will be updated as follows: Major change process: If a request is submitted to drop a major while a student is on leave, the effective date will be recorded as the date of the leave rather than the date the change was initiated. Leave of absence process: All withdrawals will be reported to the National Student Clearinghouse (NSC) manually within 2 weeks of being processed to avoid any delays or issues with the regularly scheduled Peoplesoft delivered report. If due to the schedule, a W status is reported via the delivered report instead of by hand, the person responsible for enrollment reporting will verify the status with the NSC, including program-level data. Ongoing training will be provided and a senior member of our staff will audit the major change and leave of absence processes moving forward. This corrective action plan has been implemented as of January 2025.

View Audit 340686

Finding 520854 (2024-001)

None 2024

Williams College

MA

Student Financial Aid Reporting

Management agrees with the finding and in concurrence with the recommendations we have reviewed the federal verification definitions, and the importance of selecting the correct verification status in the COD system, with staff who participate in the federal verification process to ensure they under...

Management agrees with the finding and in concurrence with the recommendations we have reviewed the federal verification definitions, and the importance of selecting the correct verification status in the COD system, with staff who participate in the federal verification process to ensure they understand the federal definition of number of family members in college. Ongoing training will be provided and a senior member of our staff will audit the verification process moving forward. This corrective action plan has been implemented as of January 2025.

View Audit 340686

Finding 520849 (2024-001)

None 2024

Concordia College

MN

Subrecipient Monitoring

Corrective Action Plan August 23, 2024 Finding 2024-001: Reporting Criteria: The Gramm-Leach-Bliley Act (Pub. L. No. 106-102) (GLBA) requires institutions to explain their information-sharing practices to their customers and to safeguard sensitive data (16 CFR 314). In 2021, the Federal Trade Commi...

Corrective Action Plan August 23, 2024 Finding 2024-001: Reporting Criteria: The Gramm-Leach-Bliley Act (Pub. L. No. 106-102) (GLBA) requires institutions to explain their information-sharing practices to their customers and to safeguard sensitive data (16 CFR 314). In 2021, the Federal Trade Commission issued final regulations that altered the current required elements of an information security program and added several new elements. Under the regulations, institutions are required to develop, implement, and maintain a comprehensive information security program that is written in one or more readily accessible parts. The written information security program for institutions must address all elements that apply. The elements for the information security programs set forth in this section 16 CFR 314.4 are high-level principles that set forth basic issues the programs must address, and do not prescribe how they will be addressed. Condition: The College does not have a written information security program that addresses all elements that apply. Cause: The College’s procedures and processes in place specific to GLBA did not have written documentation of all required elements. Effect: Failure to comply with the requirements of GLBA standards puts the College at risk of compromising consumer, nonpublic personal information. Corrective Action Planned: The College does have a written information security program but does not currently have it in the format recommended by the auditors. The College will update the documentation of all required elements, specific to GLBA, following the auditors template. Anticipated Completion Date: October 16th, 2024 Name(s) of Contact Person(s) Responsible for Corrective Action: Erik Ramstad Executive Director Information Technology

View Audit 340680

Corrective Action Plans

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