Corrective Action Plans

Finding 512113 (2024-002)

Significant Deficiency 2024

Lutheran Social Services of South Dakota

SD

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Reporting Finding Summary: The FFATA report filed for Huron School District included the incorrect Subaward Obligation/Action Da...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Reporting Finding Summary: The FFATA report filed for Huron School District included the incorrect Subaward Obligation/Action Date within the FFATA Subaward Reporting System. Corrective Action Plan: FFATA reporting requirements were reviewed after the 2023 single audit report was received to ensure management has the correct understanding of reporting terms. The report in question was prepared and filed during July 2023 which was prior to the 2023 single audit report being finalized. FFATA reports filed during April 2024 and May 2024 were properly filed. Responsible Individuals: Nathan Beyer, Emily Lyons Anticipated Completion Date: December 31, 2023

View Audit 329857

Finding 512111 (2024-002)

Material Weakness 2024

Indiana Economic Development Corporation

IN

Reporting § 200.303 § 200.329

We agree with the recommendation and as of October 2024 have implemented an additional layer of review, effective for the first round of reports filed for FY2025.

View Audit 329851

Finding 512108 (2024-001)

Significant Deficiency 2024

Family Medical Center of Michigan, Inc.

MI

Significant Deficiency Special Tests & Provisions

Family Medical Center will have management or assigned staff to review all current sliding fee patients and ensure that the Center has an updated sliding fee application for each. FMC will provide additional training to front desk staff at each site and require them to obtain the proper application ...

Family Medical Center will have management or assigned staff to review all current sliding fee patients and ensure that the Center has an updated sliding fee application for each. FMC will provide additional training to front desk staff at each site and require them to obtain the proper application and documentation. Patient Accounts will review the current application to ensure that the current patients are charged the proper sliding fee scale. Management will develop a training module with Human Resources to have each staff complete in addition to hiring additional staff. This corrective action is expected to be completed by March 31, 2025.

View Audit 329843

Finding 512081 (2024-005)

Significant Deficiency 2024

Eastern Oregon University

OR

Matching / Level of Effort / Earmarking Student Financial Aid

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the University implement procedures to ensure exit counseling notifications are sent to students who graduated or withdrew. Explanation of disagreement with audit finding: There is no disagreement with ...

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the University implement procedures to ensure exit counseling notifications are sent to students who graduated or withdrew. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office will work with our IS department to rebuild the exit counseling notifications so they are more accurate and notify the correct student population. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert Planned completion date for corrective action plan: March 21, 2025

View Audit 329796

Finding 512076 (2024-004)

Significant Deficiency 2024

Eastern Oregon University

OR

Matching / Level of Effort / Earmarking Student Financial Aid Reporting § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend the University evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely, and to sto...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend the University evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely, and to store evidence of the key control having occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office will work with our IS department to rebuild the original PELL unreported disbursements. Any unreported disbursements greater than 7 days will be reported to the financial aid director, information systems, and the vice president for finance and administration via email from Fast. This will allow for a review and timely reporting. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert Planned completion date for corrective action plan: January 6, 2025.

View Audit 329796

Finding 512071 (2024-003)

Significant Deficiency 2024

Eastern Oregon University

OR

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend the University enhance procedures for reviewing professional judgement to ensure documentation of review is stored. Explanation of disagreement with audit finding: There ...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend the University enhance procedures for reviewing professional judgement to ensure documentation of review is stored. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office (FAO) plans to do more expansive training for the Financial Aid Administrators upon hire. FAO is exploring the option of National Association of Student Financial Aid Administrators training certification for a Professional Judgment credential. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert Planned completion date for corrective action plan: February 28, 2025

View Audit 329796

Finding 512066 (2024-002)

Significant Deficiency 2024

Eastern Oregon University

OR

Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend that the University implement a key control to ensure that enrollment data, changes in status and effective dates within NSLDS match the records of the institution and ar...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend that the University implement a key control to ensure that enrollment data, changes in status and effective dates within NSLDS match the records of the institution and are reported timely, and to store evidence of the key control having occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review of Banner job to check for errors in reporting format or potential junk data that could cause a report to be rejected. New drop and withdrawal codes that only pertain to post term withdrawals and will only be used for a post term withdrawal to allow the dates to match, are being discussed. As well as internal discussion about developing key control tracking to show evidence that the controls in place are being followed. Name(s) of the contact person(s) responsible for corrective action: Emily Sharratt Planned completion date for corrective action plan: December 13, 2024

View Audit 329796

Finding 512065 (2024-001)

Significant Deficiency 2024

Eastern Oregon University

OR

Questioned Costs Matching / Level of Effort / Earmarking Student Financial Aid § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend that the University review their awarding procedures and implement procedures to ensure direct loans are awarded within student eligibility. Explanation of disagreement with audit finding: There is no d...

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend that the University review their awarding procedures and implement procedures to ensure direct loans are awarded within student eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid office (FAO) plans to do more expansive training for the Financial Aid Administrators upon hire. FAO is exploring the option of National Association of Student Financial Aid Administrators training certification for a Need Analysis credential. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert Planned completion date for corrective action plan: February 28, 2025

View Audit 329796 Questioned Costs: $1

Finding 512059 (2024-003)

Significant Deficiency 2024

Bradley University

IN

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2024-003: U.S. Department of Education. Assistance Listing Number: 84.007 (Federal Supplemental Educational Opportunity Grants Program), 84.033 (Federal Work Study Program), 84.063 (Federal Pell Grant Program), 84.268 (Federal Direct Student Loans Program). Criteria or specific requirement: The G...

2024-003: U.S. Department of Education. Assistance Listing Number: 84.007 (Federal Supplemental Educational Opportunity Grants Program), 84.033 (Federal Work Study Program), 84.063 (Federal Pell Grant Program), 84.268 (Federal Direct Student Loans Program). Criteria or specific requirement: The Gramm-Leach-Bliley Act (Public Law 106-102) requires financial institutions to explain their information-sharing practices to their customers and to safeguard sensitive data. (16 CFR 314) The Federal Trade Commission considers Title IV-eligible institutions that participate in Title IV Educational Assistance Programs as “financial institutions” and subject to the Gramm-Leach-Bliley Act (16 CFR 313.3(k)(2)(vi)). The Code of Federal Regulations 2 CFR 200.303 requires the University to establish and maintain effective internal controls over Federal awards. Context: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financial aid information, with particular attention to information provided to institutions by the Department or otherwise obtained in support of the administration of the federal student financial aid programs. Cause: The University has continued to make progress in updating the University’s written security program to become in compliance with all requirements; however, due to capacity and demands on the information technology individuals, this is still a work in process. Recommendation: We recommend the University work to update the written security program to ensure compliance with all the standards. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 329791

Finding 512057 (2024-002)

Significant Deficiency 2024

Bradley University

IN

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

2024-002: U.S. Department of Education. Assistance Listing Numbers: 84.063 - Federal Pell Grant Program, 84.268 - Federal Direct Student Loans. Criteria or specific requirement: The Code of Federal Regulations, 34 CFR 685.309 requires that enrollment status changes ...

2024-002: U.S. Department of Education. Assistance Listing Numbers: 84.063 - Federal Pell Grant Program, 84.268 - Federal Direct Student Loans. Criteria or specific requirement: The Code of Federal Regulations, 34 CFR 685.309 requires that enrollment status changes for students be reported to the National Student Loan Data System (NSLDS) within 30 days or within 60 days if the student with the status change will be reported on a scheduled transmission within 60 days of the change in status. Regulations require the status include an accurate effective date. In addition, schools are required to certify enrollment every 60 days, and respond within 15 days of the date that NSLDS sends a Roster file to the school or its third-party servicer. Errors must be corrected within 10 days. Cause: The University’s processes and controls did not ensure that student status changes were properly and timely reported to NSLDS. Effect: The errors were caused by National Student Clearinghouse's communication with NSLDS, as a result of the modernization of NSLDS in 2022. The University was told the errors would be fixed and there was nothing more they needed to do. The errors were not fixed. Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 329791

Finding 512056 (2024-001)

Significant Deficiency 2024

Bradley University

IN

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

2024-001: Student Financial Assistance Cluster. Assistance Listing Number: 84.268 - Federal Direct Student Loans. Criteria or specific requirement: The Code of Federal Regulations, 34 CFR 675.16 states whenever an institution di...

2024-001: Student Financial Assistance Cluster. Assistance Listing Number: 84.268 - Federal Direct Student Loans. Criteria or specific requirement: The Code of Federal Regulations, 34 CFR 675.16 states whenever an institution disburses FWS funds by crediting a student's account and the result is a credit balance, the institution must pay the credit balance directly to the student as soon as possible, but no later than 14 days after the credit balance occurred on the account. Cause: The student's refund was set to be sent out on but it fell on Labor day it didn't get sent out until after the 14 days. Effect: The University is not in compliance with Department of Education requirements that all credit balances be paid directly to the student as soon as possible, but no later than 14 days after the credit balance occurred. Recommendation: We recommend the University implement a process to ensure that any credit balances arising from federal student financial aid are made within the 14 day time limit imposed by the Department of Education. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 329791

Finding 512048 (2024-002)

Significant Deficiency 2024

Vermont State Colleges

VT

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

This was an isolated instance and attributed to the merger of three institution into one institution effective July 1, 2023. The registrar is monitoring the re-enrollment of students that have taken a leave of absences or have not enrolled in VTSU since the merger to identify additional errors and w...

This was an isolated instance and attributed to the merger of three institution into one institution effective July 1, 2023. The registrar is monitoring the re-enrollment of students that have taken a leave of absences or have not enrolled in VTSU since the merger to identify additional errors and will take appropriate action to correct them as the occur.

View Audit 329772

Finding 512047 (2024-001)

Significant Deficiency 2024

Vermont State Colleges

VT

Student Financial Aid Matching / Level of Effort / Earmarking

VTSU is setting standard procedures for the merged financial aid department, so all personnel are following a standard procedure. In the future, VTSU will not be marking students or using the code for “not verifying” for students who do not enroll. Posting rules are in place that will not allow aid ...

VTSU is setting standard procedures for the merged financial aid department, so all personnel are following a standard procedure. In the future, VTSU will not be marking students or using the code for “not verifying” for students who do not enroll. Posting rules are in place that will not allow aid to post to a students account if verification is incomplete.

View Audit 329772

Finding 511985 (2024-001)

Material Weakness 2024

Central Maine Growth Council

ME

Procurement, Suspension & Debarment § 200.214 § 200.318

Management at the Central Maine Growth Council is aware of its responsibility under 2 CFR 200.516(a) as it relates to the requirements to perform control activities related to suspension and debarment. • All recipients of expenditures under federal grants will be compared to the Office of Inspector...

Management at the Central Maine Growth Council is aware of its responsibility under 2 CFR 200.516(a) as it relates to the requirements to perform control activities related to suspension and debarment. • All recipients of expenditures under federal grants will be compared to the Office of Inspector General’s Exclusion Database to help ensure they are permitted to receive federal funding. This verification process will be documented and retained. • A written formal procurement policy and conflict of interest policy will be established. Responsible party: Garvan Donegan, Director of Economic Development and Strategic Projects (207) 680-7300 Anticipated completion date: December 31, 2024.

View Audit 329744

Finding 511982 (2024-001)

Material Weakness 2024

Crestwood School District

MI

Effective immediately, all Title I staff will be completing semi-annual certifications and personnel activity reports as appropriate.

View Audit 329741

Finding 511980 (2024-001)

Material Weakness 2024

Cornbelt Educational Cooperative

SD

Internal Control / Segregation of Duties Material Weakness

The Cornbelt Educational Cooperative Business Manager, Pamela Selken is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the Cooperative's business office. Staffing the office at an efficient and financia...

The Cornbelt Educational Cooperative Business Manager, Pamela Selken is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the Cooperative's business office. Staffing the office at an efficient and financially feasible level precludes the hiring of enough personnel to provide an ideal environment for the internal controls. We are aware of the weakness in internal controls and will continue to develop policies and procedures and provide compensating controls to reduce the risk. We will also communicate this concern with our Board of Directors. The Cornbelt Educational Cooperative did adopt an Internal Controls and Procedures policy on March 13th, 2018 that does address many of these issues, and would ask for consideration reflecting this implementation. This finding will be an ongoing process, requiring continued analysis of processes and procedures in order to minimize the risk.

View Audit 329740

Finding 511971 (2024-002)

None 2024

Bronson Community Schools

MI

The School will: 1. Develop procedures to ensure contractors submit certified payrolls promptly. 2. Assign a staff member to monitor compliance with the Davis-Bacon Act by reviewing certified payrolls as they are received. 3. Incorporate regular status checks with contractors to ensure wage complian...

The School will: 1. Develop procedures to ensure contractors submit certified payrolls promptly. 2. Assign a staff member to monitor compliance with the Davis-Bacon Act by reviewing certified payrolls as they are received. 3. Incorporate regular status checks with contractors to ensure wage compliance during the project.

View Audit 329729

Finding 511965 (2024-002)

Significant Deficiency 2024

Regional School Unit 34

ME

Management Response/Corrective Action Plan: Management is being made aware that all federal contractors over $2,000 will need to have the Davis Bacon/prevailing wages clause put on the estimate/quote/bid.

View Audit 329727

Finding 511963 (2024-001)

Significant Deficiency 2024

The Skillsource Group, Inc.

VA

Reporting § 200.303

Views of Responsible Officials: Upon review, the issues and errors stemmed from misclassification and oversight in the award review and categorization process, primarily due to the onboarding of a new accounting team for the organization. Moreover, the SEFA was not presented for review by agency man...

Views of Responsible Officials: Upon review, the issues and errors stemmed from misclassification and oversight in the award review and categorization process, primarily due to the onboarding of a new accounting team for the organization. Moreover, the SEFA was not presented for review by agency management before the presentation to the auditors. To correct for the future, management will implement the following corrective actions: Enhance and Expand Review Process for SEFA Preparation  Establish a checklist and review protocol to ensure that all funding awards are properly identified and classified before inclusion in the SEFA.  Conduct a secondary review of the SEFA by the Senior Vice President for Operations and the President and CEO before submission to the auditors. Cross-Referencing with Award Documentation  Implement a mandatory cross-referencing procedure to match each award’s Assistance Listing Number (ALN) with award documentation.  Require verification of funding sources, ensuring that only Federally funded awards are included on the SEFA.

View Audit 329715

Finding 511962 (2024-003)

None 2024

Comprehend Properties Inc.

KY

The property manager will be fully responsible for obtaining and documenting the receipt of the deposits. Each tenant file will have proper documentation of deposits on hand.

View Audit 329691

Finding 511961 (2024-002)

None 2024

Comprehend Properties Inc.

KY

Matching / Level of Effort / Earmarking

The property manager is responsible for providing any changes in reserve deposits to PNC Bank. This will be reviewed by the CFO to ensure the correct amount of reserve deposits is paid into the reserve.

View Audit 329691

Finding 511960 (2024-001)

Material Weakness 2024

Comprehend Properties Inc.

KY

Eligibility HUD Housing Programs

The property manager will be responsible for the calculation. The income verification documentation will be reviewed and signed off by the property manager supervisor which is the COO for Comprehend.

View Audit 329691

Finding 511958 (2024-001)

Significant Deficiency 2024

Westminster University

UT

Student Financial Aid Reporting Significant Deficiency

Westminster University is deeply committed to supporting its students and ensuring compliance with the requirements of the Student Financial Assistance Cluster. We appreciate the feedback provided in the Schedule of Findings and Questioned Costs and have taken action to address the concern raised. O...

Westminster University is deeply committed to supporting its students and ensuring compliance with the requirements of the Student Financial Assistance Cluster. We appreciate the feedback provided in the Schedule of Findings and Questioned Costs and have taken action to address the concern raised. Our institution is dedicated to continuous improvement in both our financial aid processes and overall student support services. We have developed an action plan to address the issue identified: FINDING 2024‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a policy to ensure address changes for all semesters are reported timely. Response: There is no disagreement with this audit finding. Action Taken in Response to Finding: Based upon the definition provided of Section 34 CFR Section 685.309(b) (2), it is our understanding that we are required to report address changes only on enrolled students through the period where they are marked as either (W) Withdrawn or (G) Graduated status. Our policy is to report students’ most current home address with each enrollment submission a minimum of 14 dates per year (three of which are only for graduated students) which ensures compliance with the 60-day threshold. However, our current practices have not always ensured that the current main home address was the one supplied to the National Student Clearinghouse. We will immediately implement processes to ensure that the main home address is the one sent to the National Student Clearinghouse. We consider this to be remediated. Contact Person(s): Karen Henriquez, Director of Financial Aid

View Audit 329674

Finding 511953 (2024-004)

Significant Deficiency 2024

Summit Academy Oic

MN

Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend the Academy implement MFA for individuals that access sensitive information per GLBA requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Though this finding is noted as a repe...

Recommendation: We recommend the Academy implement MFA for individuals that access sensitive information per GLBA requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Though this finding is noted as a repeat finding, I would point out that it is only the one of the eight of the safeguard elements of GLBA, the Two-Factor authentication, that was out of compliance, not the entire array of elements of GLBA. That said, Summit agrees with the finding and has implemented two-factor authentication for staff that accesses its student database. Name(s) of the contact person(s) responsible for corrective action: Marc Carrier, CFO Planned completion date for corrective action plan: Fall 2024

View Audit 329672

Finding 511950 (2024-003)

Significant Deficiency 2024

Summit Academy Oic

MN

Student Financial Aid Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Recommendation: We recommend the Academy reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since the audit, Summit Acad...

Recommendation: We recommend the Academy reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since the audit, Summit Academy has determined a new process in which we will ensure controls are being implemented within certain processes. For our R2T4’s, once the Bursar has finished the calculations, the Financial Aid Manager will review for any errors & sign off with her initials once reviewed. For NSLDS, the Financial Aid Manager will work closely with the Registrar’s Department to ensure graduates & withdrawal/terminated students are updated in a timely manner. There will also be a spreadsheet used to keep track of all students changed within NSLDS. Name(s) of the contact person(s) responsible for corrective action: Marc Carrier, CFO Planned completion date for corrective action plan: Fall 2024

View Audit 329672

Corrective Action Plans

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