FAC Explorer

Finding 966723 (2023-008)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2023
Accepted
2024-03-29
Audit: 301158
Organization: Commonspirit Health (IL)
Auditor: Ernst & Young LLP

AI Summary

  • Core Issue: CHI Health School of Radiologic Technology lacks adequate internal controls for its Satisfactory Academic Progress (SAP) policy, failing to meet federal requirements.
  • Impacted Requirements: The policy does not specify evaluation frequency, maximum timeframe, pace of progress, procedures for financial aid warnings, appeals, or student notifications.
  • Recommended Follow-Up: Implement necessary procedures to align the SAP policy with federal regulations and ensure documentation of policy reviews is maintained.

Finding Text

Finding 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR 668.16(e) states: “For purposes of determining student eligibility for assistance under a title IV, HEA program, establishes, publishes, and applies reasonable standards for measuring whether an otherwise eligible student is maintaining satisfactory academic progress in his or her educational program. The Secretary considers an institution’s standards to be reasonable if the standards are in accordance with the provisions specified in § 668.34.” 34 CFR 668.34 states: “An institution must establish a reasonable satisfactory academic progress policy for determining whether an otherwise eligible student is making satisfactory academic progress in his or her educational program and may receive assistance under the title IV, HEA programs.” The Secretary considers the institution’s policy to be reasonable if it meets the specified requirements in 34 CFR 668.34, including the following, for which we noted noncompliance by CHI Health School of Radiologic Technology.   (1) The policy provides that a student’s academic progress is evaluated— (i) At the end of each payment period if the educational program is either one academic year in length or shorter than an academic year Or (ii) For all other educational programs, at the end of each payment period or at least annually to correspond with the end of a payment period (2) The policy specifies— (i) For all programs, the maximum timeframe as defined in paragraph (b) of this section (ii) For a credit hour program using standard or nonstandard terms that is not a subscription-based program, the pace, measured at each evaluation, at which a student must progress through his or her educational program to ensure that the student will complete the program within the maximum timeframe, calculated by either dividing the cumulative number of hours the student has successfully completed by the cumulative number of hours the student has attempted or by determining the number of hours that the student should have completed by the evaluation point in order to complete the program within the maximum timeframe (3) If the institution places students on financial aid warning, or on financial aid probation, as defined in paragraph (b) of this section, the policy describes these statuses. (4) If the institution permits a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy describes— (i) How the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (ii) The basis on which a student may file an appeal: The death of a relative, an injury or illness of the student, or other special circumstances   (iii) Information the student must submit regarding why the student failed to make satisfactory academic progress, and what has changed in the student’s situation that will allow the student to demonstrate satisfactory academic progress at the next evaluation (5) If the institution does not permit a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy must describe how the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (6) The policy provides for notification to students of the results of an evaluation that impacts the student’s eligibility for title IV, HEA program funds Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding the satisfactory academic progress (SAP) policy. During our testing, we noted that the policy does not contain specific procedures related to the following components: (1) The policy does not specify the frequency of evaluation of SAP for purposes of Title IV assistance; (2) The policy does not specify the maximum timeframe or the pace at which the student must progress through the program; (3) No specific procedures exist related to disbursements to students on financial aid warning status; (4) No specific procedures exist related to appeal and reinstatement process; and (5) No specific procedures exist related to the notification to students of the evaluation process. Additionally, we noted there was no documentation retained to evidence that a review of the SAP policy was performed to ensure compliance with federal regulations. Cause: CHI Health School of Radiologic Technology did not have effective internal controls to ensure compliance with SAP requirements and did not retain sufficient documentation of review procedures over the SAP Policy. Effect or potential effect: The published SAP policy does not comply with federal requirements. Questioned costs: None. Context: CHI Health School of Radiologic Technology’s SAP policy did not include required elements according to federal regulations and there was no evidence that the SAP policy was reviewed and approved by management. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should ensure the SAP policy includes all required elements and is reviewed and approved on an annual basis with supporting documentation of the review retained. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Categories

Special Tests & Provisions Student Financial Aid Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Other Findings in this Audit

  • 390269 2023-004
    Significant Deficiency
  • 390270 2023-005
    Material Weakness Repeat
  • 390271 2023-011
    Material Weakness
  • 390272 2023-005
    Material Weakness Repeat
  • 390273 2023-006
    Material Weakness Repeat
  • 390274 2023-008
    Significant Deficiency
  • 390275 2023-009
    Significant Deficiency
  • 390276 2023-010
    Significant Deficiency Repeat
  • 390277 2023-011
    Material Weakness
  • 390278 2023-005
    Material Weakness Repeat
  • 390279 2023-006
    Material Weakness Repeat
  • 390280 2023-007
    Material Weakness Repeat
  • 390281 2023-008
    Significant Deficiency
  • 390282 2023-009
    Significant Deficiency
  • 390283 2023-010
    Significant Deficiency Repeat
  • 390284 2023-011
    Material Weakness
  • 390285 2023-012
    Significant Deficiency
  • 390286 2023-004
    Significant Deficiency
  • 390287 2023-013
    Significant Deficiency
  • 390288 2023-004
    Significant Deficiency
  • 390289 2023-001
    Material Weakness Repeat
  • 390290 2023-002
    Significant Deficiency
  • 390291 2023-004
    Significant Deficiency
  • 390292 2023-004
    Significant Deficiency
  • 390293 2023-004
    Significant Deficiency
  • 390294 2023-003
    Material Weakness Repeat
  • 390295 2023-003
    Material Weakness
  • 390296 2023-003
    Material Weakness
  • 390297 2023-003
    Material Weakness
  • 390298 2023-003
    Material Weakness
  • 390299 2023-003
    Material Weakness
  • 390300 2023-003
    Material Weakness
  • 966711 2023-004
    Significant Deficiency
  • 966712 2023-005
    Material Weakness Repeat
  • 966713 2023-011
    Material Weakness
  • 966714 2023-005
    Material Weakness Repeat
  • 966715 2023-006
    Material Weakness Repeat
  • 966716 2023-008
    Significant Deficiency
  • 966717 2023-009
    Significant Deficiency
  • 966718 2023-010
    Significant Deficiency Repeat
  • 966719 2023-011
    Material Weakness
  • 966720 2023-005
    Material Weakness Repeat
  • 966721 2023-006
    Material Weakness Repeat
  • 966722 2023-007
    Material Weakness Repeat
  • 966724 2023-009
    Significant Deficiency
  • 966725 2023-010
    Significant Deficiency Repeat
  • 966726 2023-011
    Material Weakness
  • 966727 2023-012
    Significant Deficiency
  • 966728 2023-004
    Significant Deficiency
  • 966729 2023-013
    Significant Deficiency
  • 966730 2023-004
    Significant Deficiency
  • 966731 2023-001
    Material Weakness Repeat
  • 966732 2023-002
    Significant Deficiency
  • 966733 2023-004
    Significant Deficiency
  • 966734 2023-004
    Significant Deficiency
  • 966735 2023-004
    Significant Deficiency
  • 966736 2023-003
    Material Weakness Repeat
  • 966737 2023-003
    Material Weakness
  • 966738 2023-003
    Material Weakness
  • 966739 2023-003
    Material Weakness
  • 966740 2023-003
    Material Weakness
  • 966741 2023-003
    Material Weakness
  • 966742 2023-003
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $177.08M
93.600 Head Start $5.93M
84.268 Federal Direct Student Loans $2.99M
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $1.46M
32.006 Covid-19 Telehealth Program $1.42M
93.RD Federal Contract -Unmodified and Post Translationally Modified Cd4+ $1.31M
84.063 Federal Pell Grant Program $1.12M
93.556 Marylee Allen Promoting Safe and Stable Families Program $1.02M
10.766 Community Facilities Loans and Grants $989,912
93.399 Cancer Control $930,041
93.889 National Bioterrorism Hospital Preparedness Program $875,248
93.U01 Aids Medical Waiver $858,154
16.320 Services for Trafficking Victims $855,700
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $840,877
93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund $830,161
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $818,285
14.241 Housing Opportunities for Persons with Aids $755,353
93.914 Hiv Emergency Relief Project Grants $692,962
17.277 Wioa National Dislocated Worker Grants / Wia National Emergency Grants $621,093
93.846 Arthritis, Musculoskeletal and Skin Diseases Research $547,806
93.884 Primary Care Training and Enhancement $469,308
93.778 Medical Assistance Program $419,907
93.044 Special Programs for the Aging_title Iii, Part B_grants for Supportive Services and Senior Centers $418,181
10.568 Emergency Food Assistance Program (administrative Costs) $350,683
93.211 Telehealth Programs $343,817
93.435 Innovative State and Local Public Health Strategies to Prevent and Manage Diabetes and Heart Disease and Stroke- $343,614
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $334,877
10.855 Distance Learning and Telemedicine Loans and Grants $326,268
94.011 Foster Grandparent Program $321,043
93.310 Trans-Nih Research Support $286,397
16.589 Rural Domestic Violence, Dating Violence, Sexual Assault, and Stalking Assistance Program $277,433
16.839 Stop School Violence $265,550
84.425 Education Stabilization Fund $253,328
93.697 Covid-19 Testing for Rural Health Clinics $247,338
93.011 National Organizations of State and Local Officials $234,747
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $228,312
93.324 State Health Insurance Assistance Program $221,080
93.597 Grants to States for Access and Visitation Programs $171,669
93.940 Hiv Prevention Activities_health Department Based $167,111
93.155 Rural Health Research Centers $166,844
12.420 Military Medical Research and Development $156,999
93.959 Block Grants for Prevention and Treatment of Substance Abuse $155,591
93.043 Special Programs for the Aging_title Iii, Part D_disease Prevention and Health Promotion Services $150,261
93.048 Special Programs for the Aging_title Iv_and Title Ii_discretionary Projects $137,234
20.513 Enhanced Mobility of Seniors and Individuals with Disabilities $133,162
93.276 Drug-Free Communities Support Program Grants $128,868
93.394 Cancer Detection and Diagnosis Research $127,316
16.842 Opioid Affected Youth Initiative $122,054
93.301 Small Rural Hospital Improvement Grant Program $109,387
93.837 Cardiovascular Diseases Research $105,714
94.002 Retired and Senior Volunteer Program $104,948
93.686 Ending the Hiv Epidemic: A Plan for America — Ryan White Hiv/aids Program Parts A and B (b) $96,247
16.575 Crime Victim Assistance $92,922
10.572 Wic Farmers' Market Nutrition Program (fmnp) $92,866
16.582 Crime Victim Assistance/discretionary Grants $80,735
93.053 Nutrition Services Incentive Program $77,049
93.327 Demonstration Grants for Domestic Victims of Severe Forms of Human Trafficking $70,095
93.279 Drug Abuse and Addiction Research Programs $67,547
94.016 Senior Companion Program $61,403
93.650 Accountable Health Communities $61,346
93.350 National Center for Advancing Translational Sciences $60,982
84.007 Federal Supplemental Educational Opportunity Grants $58,772
10.331 Food Insecurity Nutrition Incentive Grants Program $50,367
93.840 Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders $49,893
93.788 Opioid Str $49,081
93.359 Nurse Education, Practice Quality and Retention Grants $48,733
97.024 Emergency Food and Shelter National Board Program $45,539
93.241 State Rural Hospital Flexibility Program $42,825
93.558 Temporary Assistance for Needy Families $34,572
93.RD Federal Contract - Intergovernmental Personnel $29,238
93.069 Public Health Emergency Preparedness $27,131
93.268 Immunization Cooperative Agreements $26,945
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $26,503
93.855 Allergy and Infectious Diseases Research $24,412
93.866 Aging Research $24,297
93.994 Maternal and Child Health Services Block Grant to the States $23,921
93.667 Social Services Block Grant $20,582
93.575 Child Care and Development Block Grant $20,531
93.RD Federal Contract - Infections, Microbiome and Hla-Dr in the Induction of Lupos Related Auto-Antibodies $19,816
93.658 Foster Care_title IV-E $15,610
93.426 Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke $15,000
94.021 Americorps Volunteer Generation Fund $14,705
93.839 Blood Diseases and Resources Research $14,637
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $13,136
93.991 Preventive Health and Health Services Block Grant $11,030
93.RD Federal Contract - Tn-27: A Multiple Ascending Dose Trial - Investigating Safety, Tolerability and Parmacokinetics of Nnc03 $10,627
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $10,150
93.121 Oral Diseases and Disorders Research $5,631
93.RD Federal Contract - Tn01 - Pathway to Prevention $5,527
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $5,000
93.045 Special Programs for the Aging_title Iii, Part C_nutrition Services $4,900
93.071 Medicare Enrollment Assistance Program $4,782
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $4,570
93.RD Federal Contract - Tn-22: Hyroxychloroquine Prevention $4,457
93.865 Child Health and Human Development Extramural Research $4,373
84.181 Special Education-Grants for Infants and Families $4,143
10.558 Child and Adult Care Food Program $3,713
93.395 Cancer Treatment Research $3,238
93.113 Environmental Health $3,222
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $2,849
20.616 National Priority Safety Programs $2,486
93.568 Low-Income Home Energy Assistance $2,476
93.RD Federal Contract - Tn-25: Rituximab Followed by Abatacept for Prevention Or Reversal of Type 1 Diabetes (t1d) $2,253
93.838 Lung Diseases Research $1,413
93.396 Cancer Biology Research $993
97.067 Homeland Security Grant Program $702
93.RD Federal Contract - Tn-16: Long Term Investigative Follow-Up in Trialnet $531
97.008 Non-Profit Security Program $417
93.RD Federal Contract - Tn-18: Prevention of Abnormal Glucose Tolerance and Diabetes in Relatives At-Risk for T1d Mellitus $352
93.RD Federal Contract - Tn-28: Low Dose Atg in Prevention $7