Corrective Action Plans

Finding 514654 (2024-004)

Material Weakness 2024

Lebanon Community Unit School District 9

IL

Management will reinforce procedures to gather the required information for the reports and set reminders to ensure that they will be filed in a timely manner.

View Audit 333056

Finding 514652 (2024-006)

Material Weakness 2024

Housing Authority of Winchester

KY

Management should assure environmental testing is performed timely

View Audit 333040

Finding 514651 (2024-005)

Material Weakness 2024

Housing Authority of Winchester

KY

HUD Housing Programs

Management should perform flat rent and move in inspections and document those procedures.

View Audit 333040

Finding 514650 (2024-002)

None 2024

Illinois Valley Community College Dist. No.513

IL

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

2024-002: Missing Exit Counseling Documentation - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing, we noted two students out of 40 did not have documentation in their file t...

2024-002: Missing Exit Counseling Documentation - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing, we noted two students out of 40 did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be an instance of non-compliance with the Eligibility Compliance Requirement. Corrective Action Plan We have updated our Loan Procedures to include running an internal report on all loan students on the 1st and 15th of every month, or the next work day following those dates if they land on a day the campus is closed. If a student with loans has withdrawn completely and stopped attending, we will send an exit letter within 7 business days of discovering that the student has ceased attending. Responsible Person for Corrective Action Plan Isamar Taylor - Director of Financial Aid and Jill Wohrley - Financial Aid Reconciliation and Compliance Specialist Implementation Date of Corrective Action Plan 10/16/2024

View Audit 333030

Finding 514648 (2024-001)

Significant Deficiency 2024

Illinois Valley Community College Dist. No.513

IL

Special Tests & Provisions Student Financial Aid Reporting

2024-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster – Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition Found During our Return of Title IV Fund testing, we noted that the College did not return Title IV Student Finan...

2024-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster – Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition Found During our Return of Title IV Fund testing, we noted that the College did not return Title IV Student Financial Aid for five out of twenty-five students tested until after 45 days when the student ceased attendance. We consider the untimely calculation and Return of Title IV Student Financial Aid to be a Significant Deficiency relating to the Special Tests and Provisions Compliance Requirement. Corrective Action Plan To rectify this issue, we have taken the following corrective actions: Enhanced Monitoring and Reporting: Run our internal tracking report once a week to monitor and ensure timely Return of Title IV (R2T4) calculations. This system will alert financial aid staff when a student withdraws, prompting immediate action to review and process the return within the required 45-day timeframe. Staff Training and Certification: Conducted a comprehensive training session for all financial aid staff to reinforce the importance of timely R2T4 calculations. Training covered procedures for identifying students who have ceased attendance, the calculation process, and deadlines for completing returns. Regular refresher training sessions will be scheduled each term to ensure staff remain informed and compliant with federal guidelines. Audit and Quality Control Checks: Institute periodic quality control checks by the Financial Aid Reconciliation and Compliance Specialist to verify the accuracy and timeliness of R2T4 calculations. Responsible Person for Corrective Action Plan Isamar Taylor - Director of Financial Aid and Jill Wohrley - Financial Aid Reconciliation and Compliance Specialist Implementation Date of Corrective Action Plan 10/16/2024

View Audit 333030

Finding 514643 (2024-001)

Significant Deficiency 2024

Plains Independent School District

TX

2024-001 – Significant Deficiency in Controls – Semi-Annual Certification Forms

View Audit 333018

Finding 514643 (2024-001)

Significant Deficiency 2024

Plains Independent School District

TX

Responsible Party: Robert McLain, Superintendent

View Audit 333018

Finding 514643 (2024-001)

Significant Deficiency 2024

Plains Independent School District

TX

Corrective Action Plan: Proper time and effort documentation, including semi-annual certifications, if necessary, will be required for all employees paid from federal awards to ensure compliance with the District’s federal grant manual and 2 CFR 200.430.

View Audit 333018

Finding 514643 (2024-001)

Significant Deficiency 2024

Plains Independent School District

TX

Expected Completion Date: Immediately

View Audit 333018

Finding 514636 (2024-004)

Significant Deficiency 2024

Dodge City Community College

KS

Student Financial Aid

Condition: During our review of the return of Title IV funds, we noted that students were not being properly identified as withdrawn, either officially or unofficially. This resulted in 4 students noted that never had a calculation performed, but should have, and 4 students that were reported late....

Condition: During our review of the return of Title IV funds, we noted that students were not being properly identified as withdrawn, either officially or unofficially. This resulted in 4 students noted that never had a calculation performed, but should have, and 4 students that were reported late. Criteria: When a recipient of Title IV funds withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must perform a Return of Title IV Funds calculation to determine the amount of Title IV assistance the student earned as of the student’s withdrawal date. Cause: Student Financial Aid personnel did not have a method to properly identify students who are required to have a return of funds calculation. Effect: Funds required to be sent back to the Department of Education are either missed or are late. Perspective: There has been high turnover in the SFA department, including a time where there was not a Director in place. Significant personnel changes were made at the end of the June 30, 2024 year. Reports are being obtained from IT department regularly. Recommendation: We recommend training of Student Financial Aid personnel on the rules and regulations over return of funds. In addition, we recommend that Student Financial Aid personnel work with the IT department to develop a report that can be ran weekly or bi-weekly to identify the students and timely prepare the calculations. Views of Responsible Officials and Planned Corrective Actions: Dodge City Community College staff involved are undergoing training to learn requirements. Processes and procedures have been developed to ensure timely calculations and refunds.

View Audit 333007

Finding 514632 (2024-003)

Significant Deficiency 2024

Dodge City Community College

KS

Student Financial Aid Matching / Level of Effort / Earmarking

Condition: There were no monthly Title IV reconciliations performed. Criteria: Per SFA requirements, the College is required to reconcile the COD data files with the College’s financial records. Cause: Turnover in the staff and Director positions of the College. The new employees were not aware o...

Condition: There were no monthly Title IV reconciliations performed. Criteria: Per SFA requirements, the College is required to reconcile the COD data files with the College’s financial records. Cause: Turnover in the staff and Director positions of the College. The new employees were not aware of this requirement. Effect: Noncompliance with SFA requirements. Perspective: Significant personnel changes were made at the end of the June 30, 2024 year. There were also new written standard operating policies and procedures implemented. Auditor sighted new policies and new spreadsheets. We also noted that monthly reconciliations have begun and are occurring monthly. Recommendation: We recommend that the direct loans are reconciled at least monthly between the COD and the College’s general ledger. Views of Responsible Officials and Planned Corrective Actions: Dodge City Community College staff involved have received training and been made aware of requirements. Monthly reconciliations will be performed immediately.

View Audit 333007

Finding 514631 (2024-002)

Significant Deficiency 2024

Dodge City Community College

KS

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Condition: We examined a sample of Title IV aid recipients to verify that information reported on the Enrollment Reporting roster file sent to the National Student Loan Data System (NSLDS) matched the student's academic files and found instances where students received Title IV aid during a semester...

Condition: We examined a sample of Title IV aid recipients to verify that information reported on the Enrollment Reporting roster file sent to the National Student Loan Data System (NSLDS) matched the student's academic files and found instances where students received Title IV aid during a semester but the status of withdrawn or graduate were not reported correctly or timely on the NSLDS Enrollment Reporting roster files sent during that semester. Criteria: Per the NSLDS Enrollment Reporting Guide, a school should report all students that NSLDS includes in its request to the school on a roster file. This includes timely and accurate reporting of the status of the student of withdrawn or graduate. Cause: The status of the students were not timely and accurately reported to NSLDS. Effect: Students could potentially not be placed in grace or repayment status when they should be. Perspective: Condition is still present in part. All withdrawn students tested were reported accurately and timely. There were still some graduates that were not reported until first of term submission rather than when the Graduates only report was submitted. There has been high turnover in the SFA department, including a time where there was not a Director in place. The new Director came on at the end of the June 30, 2024 year and is working to correct the reporting. Recommendation: We recommend that personnel in charge of enrollment reporting be diligent in reviewing the roster file to ensure that all appropriate students are shown and attendance changes are reported in a timely and accurate manner. We also recommend contacting the Clearinghouse to ensure the correct reports are being used by the Clearinghouse and possibly changing the deadline for submission of the Graduates only report as it currently has a very quick turnaround and not all grades are known or submitted by the current deadline. Views of Responsible Officials and Planned Corrective Actions: Dodge City Community College staff involved in enrollment reporting to the NSLDS have reviewed the NSLDS Reporting Manual to better understand and accurately report the student's enrollment status. There has been high turnover in the SFA department, including a time where there was not a Director in place. The new Director came on in the in June 2024. The College is still working on fully implementing new procedures and catching up submissions.

View Audit 333007

Finding 514620 (2024-001)

Significant Deficiency 2024

Town of Oro Valley, Arizona

AZ

Equipment & Real Property Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.313

Town management concurs with the finding, and while audit staff were still onsite for field work, Town staff implemented and added tracking and documentation information for all federally funded capital assets, to include unique descriptors, Catalog of Federal Domestic Assistance grant number, fundi...

Town management concurs with the finding, and while audit staff were still onsite for field work, Town staff implemented and added tracking and documentation information for all federally funded capital assets, to include unique descriptors, Catalog of Federal Domestic Assistance grant number, funding source and amount. In addition, inventory counts for federally funded assets will be conducted and recorded at least once every two years.

View Audit 332988

Finding 514616 (2024-002)

None 2024

Kankakee Community College District 520

IL

Reporting Internal Control / Segregation of Duties

2024-002: Enrollment Reporting - Student Financial Aid Cluster -Assistance Listing Number 84.007, 84.033, 84.063, and 84.268 - Year Ended June 30, 2024 Condition: During our Enrollment Status Changes testing, we selected forty students for our sample. In our sample of forty we tested twenty graduate...

2024-002: Enrollment Reporting - Student Financial Aid Cluster -Assistance Listing Number 84.007, 84.033, 84.063, and 84.268 - Year Ended June 30, 2024 Condition: During our Enrollment Status Changes testing, we selected forty students for our sample. In our sample of forty we tested twenty graduated students to verify that they were reported within sixty days and we tested twenty current students to note that their student status is reported correctly. We noted two students were not reported within the required sixty days. We consider this finding to be an instance of noncompliance relating to the Reporting Compliance Requirement. Corrective Action Plan: The KCC Office of Adminssions and Registration has reviewed and updated the Graduation Reporting process to ensure compliance standards are consistently met. The scehdule for graduated students has been updated to ensure students are being reporting within sixty days from conferral date. Responsible Person for Corrective Action Plan: Michelle Hasik, Director of Enrollment Services Implementation Date of Corrective Action Plan: November 1, 2024

View Audit 332960

Finding 514615 (2024-001)

None 2024

Kankakee Community College District 520

IL

Special Tests & Provisions Student Financial Aid Reporting

2024-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster – Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition: During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV Stude...

2024-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster – Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2024 Condition: During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV Student Financial Aid for two out of twenty-five students tested until after 45 days when the student ceased attendance. We consider the untimely calculation and Return of Title IV Student Financial Aid to be an instance of noncompliance relating to the Special Tests and Provisions Compliance Requirement. Corrective Action Plan: The KCC Office of Financial Aid has reviewed and updated the Return of Title IV process to ensure compliance standards are consistently met. A weekly report has been set up to detect unprocessed R2T4 awards and transmittal will occur on a weekly basis to support the timely return of Title IV funds. Responsible Person for Corrective Action Plan: Kendra Souligne, Director of Financial Aid & Student Engagement Implementation Date of Corrective Action Plan: June 12, 2024

View Audit 332960

Finding 514614 (2024-004)

Significant Deficiency 2024

Sma Healthcare, Inc.

FL

Allowable Costs / Cost Principles

For ALN 93.558, a Master Treatment Plan was not completed for 5 of the 40 clients tested within the established timeframe. As a corrective action, the program director will provide training to the team members of the program's proper established timeframe to complete a Master Treatment Plan. In addi...

For ALN 93.558, a Master Treatment Plan was not completed for 5 of the 40 clients tested within the established timeframe. As a corrective action, the program director will provide training to the team members of the program's proper established timeframe to complete a Master Treatment Plan. In addition, SMA will monitor the program by completing internal record reviews. The results will be provided to the program director and if a 90% or higher is not achieved for 2 months, a written corrective action will be required, and a verbal will be required at the quarterly Quality Assurance Committee meeting.

View Audit 332958

Finding 514613 (2024-002)

Significant Deficiency 2024

Sma Healthcare, Inc.

FL

Allowable Costs / Cost Principles Eligibility

For ALN 93.959, a Financial Assessment Form was not properly signed for 1 of the 60 clients tested. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form completion date. Obtaining a client's signature on the form has been chall...

For ALN 93.959, a Financial Assessment Form was not properly signed for 1 of the 60 clients tested. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form completion date. Obtaining a client's signature on the form has been challenging, particularly during recent years as use of telehealth services has expanded. As a corrective action, team members will be trained in how to properly document receipt of verbal approval. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As a corrective action plan, SMA will include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.

View Audit 332958

Finding 514612 (2024-001)

Significant Deficiency 2024

Sma Healthcare, Inc.

FL

Allowable Costs / Cost Principles Eligibility

For ALN 93.958, the discount fee that was shown on their Financial Assessment Form was not used for 7 of the 60 clients tested. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form. Our internal tracking of completion of the Fi...

For ALN 93.958, the discount fee that was shown on their Financial Assessment Form was not used for 7 of the 60 clients tested. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As acorrective action, the Client Service Specialist will be trained to ensure data is entered accurately. SMA will also include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.

View Audit 332958

Finding 514595 (2024-001)

Material Weakness 2024

Niad Center for Human Development, Inc. D/b/a Crisis Intervention Services

IA

Internal Control / Segregation of Duties

As documented in our response to the auditor's comment, we plan to monitor and segregate duties as efficiently as possible

View Audit 332943

Finding 514591 (2024-001)

None 2024

County of Henrico, Virginia

VA

Questioned Costs Eligibility School Nutrition Programs

2024-001 - Nonmaterial Noncompliance - Eligibility Program: Child Nutrition Cluster (ALN 10.553 and 10.555) - United States Department of Agriculture; Federal Award Year: 2024 Responsible Officials: John Wack, Chief Financial Officer, Henrico County Public Schools Planned Corrective Action: School N...

2024-001 - Nonmaterial Noncompliance - Eligibility Program: Child Nutrition Cluster (ALN 10.553 and 10.555) - United States Department of Agriculture; Federal Award Year: 2024 Responsible Officials: John Wack, Chief Financial Officer, Henrico County Public Schools Planned Corrective Action: School Nutrition Services Leadership has put a new process in place, to run a report from the point-of-sale system weekly, that will catch any "Manual" updates to lunch statuses. This report will be run weekly and verified by either the Dietitian or Controller. The report will be initialized and kept on file. Expected Completion Date: 12/31/24

View Audit 332941 Questioned Costs: $1

Finding 514589 (2024-001)

None 2024

Gardner-Webb University

NC

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

We acknowledge the finding 2024-001 regarding the untimely reporting to the NSLDS and understand the importance of adhering to the prescribed reporting timelines to ensure that student loan and grant information is accurate and up-to-date. We take this matter seriously and are committed to rectifyin...

We acknowledge the finding 2024-001 regarding the untimely reporting to the NSLDS and understand the importance of adhering to the prescribed reporting timelines to ensure that student loan and grant information is accurate and up-to-date. We take this matter seriously and are committed to rectifying the situation as quickly as possible. Root Cause: The root cause of the late reporting to NSLDS was primarily attributed to employee turnover within the department responsible for data reporting. Specifically, the loss of key personnel during the reporting period led to a temporary breakdown in the continuity of reporting processes. This turnover resulted in insufficient staffing which caused delays in the submission of required reports to the National Student Clearinghouse and, thus, NSLDS. Corrective Actions: • We are in the process of reviewing and streamlining the reporting process to increase efficiency and reduce the likelihood of delays. • Additionally, we are reviewing backup procedures to ensure that in the event of further turnover, there is a well-documented and easily transferable knowledge base for the remaining staff. Conclusion: We take the findings of the audit seriously and are committed to improving our processes and addressing the root causes of late reporting. The corrective actions outlined above are designed to prevent recurrence of this issue, ensure compliance with NSLDS reporting deadlines, and improve overall reporting accuracy and timeliness. Linda Fleischman, Registrar, 704-406-4263

View Audit 332940

Finding 514583 (2024-002)

Significant Deficiency 2024

University of Northwestern - St. Paul and Subsidiaries

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Variou Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is n...

Student Financial Assistance Cluster – Assistance Listing No. Variou Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will update our procedures to make sure we are reporting accurate graduate dates and enrollment effective dates in a timely manner. We have already begun reviewing this and are finding that the incidents found appear to be isolated. Therefore we are updating procedure to include additional quality control checks to ensure that anomalies are found and resolved within the required timeframe. Name(s) of the contact person(s) responsible for corrective action: Hannah Blahnik Planned completion date for corrective action plan: May 2025

View Audit 332923

Finding 514577 (2024-001)

Significant Deficiency 2024

University of Northwestern - St. Paul and Subsidiaries

MN

Significant Deficiency Equipment & Real Property Management Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit ...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  An Information Security Policy that addresses all policy gaps related to the GLBA audit findings will be presented to the President’s cabinet for approval by Dec. 2, 2024.  A migration of our Banner environment to Oracle Cloud Infrastructure will be completed by Nov. 6, 2024. This will include encrypting our database at rest, which is the last step in implementing best practices for encrypting our Banner data.  In addition to our annual security awareness training, we will complete an organizationwide phishing simulation by Dec. 31, 2024. Name(s) of the contact person(s) responsible for corrective action: Chad Miller Planned completion date for corrective action plan: December 31, 2024

View Audit 332923

Finding 514569 (2024-004)

Material Weakness 2024

Clarenceville School District of Oakland and Wayne Counties

MI

Subrecipient Monitoring Cash Management Material Weakness

Condition: The School District is required to account for all revenues and expenditures of its non-profit school food service account in accordance with state and federal requirements. In order to ensure that federal reimbursement payments received monthly from the Michigan Department of Education a...

Condition: The School District is required to account for all revenues and expenditures of its non-profit school food service account in accordance with state and federal requirements. In order to ensure that federal reimbursement payments received monthly from the Michigan Department of Education are correctly credited to the school food service account, monthly bank reconciliations should be prepared and reviewed by individuals with requisite skill and experience. During the 2024 fiscal year, bank reconciliations and monthly reconciliations of food service revenues and expenditures of the school food service account were not being prepared and reviewed in a timely manner. As there was an unexpected reduction in staff resources in the business office, there were not adequate resources to perform these accounting reconciliations on a timely regular basis during the year. The absence of these timely regular reviews could lead to undiscovered errors in the school food service account and material noncompliance with federal regulations. Planned Corrective Action: The School District agrees that its internal control structure should ensure that accounting reconciliations are prepared and reviewed in a timely manner during the year. Although the School District had an intergovernmental Agreement with its Intermediate School District to provide business services, such services could not be rendered due to inability to find staffing. Near the end of the 2024 fiscal year, a Finance Director was directly hired into the business office. Monthly reconciliations of accounting records and closing of monthly books are now being performed and reviewed on a timely basis. Contact person responsible for corrective action: David Bergeron, Assistant Superintendent Anticipated Completion Date: July 1, 2024

View Audit 332905

Finding 514565 (2024-003)

Material Weakness 2024

Clarenceville School District of Oakland and Wayne Counties

MI

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Condition: The School District must submit monthly claims for reimbursement for meals served to eligible students within 60 days following the last day of the month covered by the claim (7 CFR sections 210.8, 220.11, 215.10, and 225.15 (c)). Upon preparation of meal reimbursement claims, the School ...

Condition: The School District must submit monthly claims for reimbursement for meals served to eligible students within 60 days following the last day of the month covered by the claim (7 CFR sections 210.8, 220.11, 215.10, and 225.15 (c)). Upon preparation of meal reimbursement claims, the School District is required to have controls in place to ensure the accuracy of the request for reimbursement. The School District did not have a documented review process in place over the reimbursement requests. Meal counts entered into the Michigan Nutrition Data (MIND) system took place without a secondary review, which could result in incorrect reporting of the number of meals. The preparation of the request without a secondary review could result in incorrect reporting of the number of free and reduced priced meals, which could result in the School District being reimbursed an incorrect amount by the Michigan Department of Education. Planned Corrective Action: The School District's business office performed a detailed review of all meal claim submissions for the 2023-2024 fiscal year. Claims were accurately completed as was the amount of reimbursement paid by the Michigan Department of Education. The business office has since implemented a formalized internal control procedure beginning in July 2024, whereby a formal documented review of the meal claim submission is performed. Contact person responsible for corrective action: David Bergeron, Assistant Superintendent Anticipated Completion Date: July 1, 2024

View Audit 332905

Corrective Action Plans

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