Corrective Action Plans

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Significant Deficiency 2025-002 (Internal Control Over Federal Award Reporting – ESSER III) Federal Program: Education Stabilization Fund - ARP-ESSER ALN: 84.425U Condition: Allowable ESSER III expenditures incurred during fiscal year 2023-24 were not identified or included on the Schedule of Expend...
Significant Deficiency 2025-002 (Internal Control Over Federal Award Reporting – ESSER III) Federal Program: Education Stabilization Fund - ARP-ESSER ALN: 84.425U Condition: Allowable ESSER III expenditures incurred during fiscal year 2023-24 were not identified or included on the Schedule of Expenditures of Federal Awards (SEFA) for that year. In addition, expenditures related to Federal Set-Aside awards were mistakenly included in the Final Expenditure Report for ESSER III, resulting from a misunderstanding of the structure of the federal awards. Recommendation: Strengthen internal controls Corrective Action: The District will provide targeted training to staff responsible for federal grant accounting to ensure a clear understanding of federal grant award structures, including the distinction between ESSER III and related Federal Set-Aside awards. This training will cover grant setup, expenditure coding, and reporting requirements. Person Responsible: Brenda VanBuskirk, Business Manager Proposed Completion Date: December 31, 2025
Information on the federal program: Subject: Special Education Cluster (IDEA) – Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal ...
Information on the federal program: Subject: Special Education Cluster (IDEA) – Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 22611-047-PN01, 22611-047-ARP, 22619-047-PN01, 22619-047-ARP Pass-Through Entity: Indiana Department of Education Compliance Requirement: Period of Performance Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Special Education Cluster program and Period of Performance compliance requirements. Context: During fiscal year 2023-24, the School Corporation was a member of Cooperative School Services (Cooperative). The Cooperative operated the special education programs and spent the federal money on behalf of its member schools. As the grant agreement was between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. For Special Education Cluster awards, funds must be obligated during the 27 months, extending from July 1 of the fiscal year for which the funds were appropriated through September 30 of the second following fiscal year. When testing transactions occurred in the liquidation period for the 22611-047-PN01, 22611-047-ARP, 22619-047-PN01 and 22619-047-ARP grant awards, two exceptions were identified in the sample of five transactions. For the above listed awards, costs must be obligated by September 30, 2023. For the two identified exceptions, an initial purchase order was made in September, but the ultimate transaction was paid to a separate vendor than the original purchase order, and this obligation was incurred in November 2023. This issue was isolated to fiscal year 2024. No costs incurred outside of the period of performance were identified in fiscal year 2025. Views of Responsible Officials and Corrective Action Plan: Management disagrees with part of the finding. The term “obligate” can be interpreted in various ways within our context. While we have a purchase order that was completed by September 30, we do agree that we changed vendors after September 30 and paid the non-public school directly. We agree with the finding that direct payment to a non-public school is not allowable. The purchase order is an internal written commitment to acquire the items/supplies, but it is not a binding written agreement to acquire “property” when we are purchasing supplies until it is provided to the vendor. The purchase order is authorization and approval to purchase the items/supplies. Once the purchase order is provided to the vendor, it is committed and is the binding written agreement. The invoice is an order to pay the obligation. Responsible Party and Timeline for Completion: Corrective action plan has been implemented as this finding impacted fiscal year 2024 but did not recur in fiscal year 2025. Sarah Claton, Cooperative School Services director, and Tracy Albertson, Director of Finance, will oversee the corrective action plan to monitor the cooperative on an ongoing basis.
Information on the federal program: Subject: Special Education Cluster (IDEA) – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers...
Information on the federal program: Subject: Special Education Cluster (IDEA) – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 22611-047-PN01, 22611-047-ARP, 22619-047-ARP, 24611-047-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Special Education Cluster program and Activities Allowed or Unallowed and Allowable Costs compliance requirements. Context: During fiscal year 2023-2024, the School Corporation was a member of Cooperative School Services (Cooperative). The Cooperative operated the special education programs and spent the federal money on behalf of its member schools. As the grant agreement was between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. For costs related to non-public schools, the practice of the Cooperative was to separate out the required amount for each member school from the Cooperative budget, and the member schools would work with the non-public schools to determine how to spend their proportionate share amount. Each member school would then request reimbursement from the Cooperative for non-public school expenditures incurred. This allowed both the Cooperative and member schools to maintain control of all Special Education funds, property, equipment and supplies. In the initial sample of 25 expenditures, there was no noncompliance identified. However, while performing a review of separate transactions for the Period of Performance compliance requirement, it was noted that non-public schools received direct reimbursements from the Cooperative for their proportionate share expenditures, which is not allowable under the grant award. The audit team reviewed the expenditure population in entirety and identified a total of 5 expenditures, totaling $17,857, that were made from Special Education funds directly to non-public schools by the cooperative during the audit period. The lack of controls and noncompliance was an isolated to the 22611-047-PN01, 22611-047-ARP, 22619-047-ARP and 24611-047-PN01 grant awards. This issue was isolated to fiscal year 2024. No direct payments to non-public schools were identified during fiscal year 2025. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding. During the required consultation meeting involving the Local Educational Agency (LEA), representatives from private schools, and the parents or legal guardians of nonpublic students with disabilities, the agenda will cover both allowable and un-allowed costs. The meeting agenda will clearly outline that all purchased items are the responsibility of the LEA, that gift cards are prohibited, and that all acquisitions must provide direct benefit to students with disabilities. Responsible Party and Timeline for Completion: Corrective action plan has been implemented as this finding impacted fiscal year 2024 but did not recur in fiscal year 2025. Sarah Claton, Cooperative School Services Director, and Tracy Albertson, Director of Finance, will oversee the corrective action plan to monitor the cooperative on an ongoing basis.
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
Westminster College Corrective Action Plan (CAP) Federal Program: Economic Adjustment Assistance Program, Assistance Listing Number 11.307 Finding 2025-001: Questioned Costs – Allowable Costs/Costs Principles (material weakness) Name of Contact Person: Gerald J. Ganz, Jr., Vice President, CFO Specif...
Westminster College Corrective Action Plan (CAP) Federal Program: Economic Adjustment Assistance Program, Assistance Listing Number 11.307 Finding 2025-001: Questioned Costs – Allowable Costs/Costs Principles (material weakness) Name of Contact Person: Gerald J. Ganz, Jr., Vice President, CFO Specific Corrective Action: To prevent recurrence, the College is implementing the following measures: 1. Enhanced Funding Source Review Procedures: The College will develop and enforce a standardized review process requiring staff to verify and document the original funding source for any expenditure prior to charging it to a federal award. This process will include mandatory cross-checking between project accounting records, bond expenditures logs, and grant reimbursement requests. 2. Strengthened Internal Controls Over Capital Project Accounting: The College will implement additional controls within the accounting system to ensure expenditures tied to capital projects are flagged and reviews for potential dual funding before being charged to any federal program. 3. Training and Guidance for Staff: All personnel involved in grant management, accounting, and capital project administration will receive updated training on Cost Principles under 2 CFR 200.400-200.406, with emphasis on allocability, reasonableness, and the proper handling of applicable credits. 4. Ongoing Monitoring and Review: Quarterly internal compliance reviews will be conducted to confirm adherence to the new procedures, and corrective measures will be taken immediately if discrepancies are identified. The College is committed to ensuring full compliance with federal regulations and strengthening internal controls to safeguard all funding sources. We appreciate the opportunity to improve our processes and will implement the recommended procedures to ensure the integrity of future federal program expenditures. Anticipated Completion Date: June 30, 2026
Finding 2025-002 Reporting Department’s Response: Management agrees with this finding. Corrective Action: This issue arose during the onboarding of students admitted through a teach-out arrangement with a closing institution. Because these students entered under program structures that differed from...
Finding 2025-002 Reporting Department’s Response: Management agrees with this finding. Corrective Action: This issue arose during the onboarding of students admitted through a teach-out arrangement with a closing institution. Because these students entered under program structures that differed from NUNM’s standard enrollment models, some of the information initially received did not align with NUNM’s financial aid packaging assumptions. In two cases, cost of attendance calculations reflected full-time status when the program design required three-quarter-time treatment. While the situation was limited to a small number of students within a unique population, management recognizes that our internal coordination processes did not sufficiently account for the complexity of the teach-out transition. In particular, clearer confirmation of enrollment status and program structure should have occurred before aid was packaged and originated. Management is strengthening procedures for any future teach-out, transfer, or non-standard admissions cohorts to ensure accurate and compliant packaging from the outset. Going forward, NUNM will implement the following controls: • A standardized handoff process from Admissions to Financial Aid for special populations that documents program structure, term length, and expected enrollment level prior to packaging. • A secondary review requirement for initial aid awards for new program types or cohorts before loans are originated. • Regular cross-functional checkpoints between Admissions and Financial Aid during the setup of non-standard programs. Management views this experience as an opportunity to improve coordination and compliance during periods of institutional transition and is committed to maintaining strong controls over Title IV packaging and cost of attendance calculations. Contact: Jerry Bores Anticipated Completion Date: Immediately
We have a multi-pronged action plan. We will clarify and review our accounting policies and procedures regarding payroll allocations with staff; We will create a more thorough documentation process of the basis for each allocation; We will review the assumptions used for allocations during the year ...
We have a multi-pronged action plan. We will clarify and review our accounting policies and procedures regarding payroll allocations with staff; We will create a more thorough documentation process of the basis for each allocation; We will review the assumptions used for allocations during the year and update them (as needed); We will include regular monitoring and review of payroll allocations.
Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.
Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.
The campus agrees with the finding. To address this issue and prevent recurrence, Los Angeles Southwest College will implement the following corrective actions: 1. Policy Implementation and Alignment: Fully implement District time and effort policies at the College level, with clear guidance on docu...
The campus agrees with the finding. To address this issue and prevent recurrence, Los Angeles Southwest College will implement the following corrective actions: 1. Policy Implementation and Alignment: Fully implement District time and effort policies at the College level, with clear guidance on documentation requirements for employees funded by multiple federal awards. 2. Standardized Procedures: Utilize the establish standardized procedures and templates for time and effort reporting, including defined timelines for completion, supervisory review, and record retention. 3. Training and Communication: Provide mandatory training for grant-funded employees, supervisors, and administrators on federal time and effort requirements and District procedures. 4. Oversight and Monitoring: Designate responsible administrators to monitor compliance, conduct periodic internal reviews, and ensure records are properly maintained and readily available in multiple platforms. Los Angeles Southwest College is committed to strengthening its internal controls, ensuring full compliance with federal and District requirements, and maintaining accurate and reliable documentation to support all federally funded activities. Personnel Responsible for Implementation: Dr. Tangelia Alfred. Position of Responsible Personnel: Vice President of Student Services Expected Date of Implementation: January 5, 2026
Management concurs with the finding and recommendation. The condition resulted from a process gap in which payroll reallocations were made to comparable programs without a corresponding post-adjustment review against certified time and effort documentation. While initial certifications were obtained...
Management concurs with the finding and recommendation. The condition resulted from a process gap in which payroll reallocations were made to comparable programs without a corresponding post-adjustment review against certified time and effort documentation. While initial certifications were obtained, a control step was not in place to ensure that subsequent allocation changes remained aligned with after-the-fact certifications. To address this, program management will implement a formal, standardized time and effort process that includes periodic after-the-fact certifications and a required reconciliation between certified effort and payroll distributions before charges are finalized to federal awards. Management will also establish clear internal controls to govern reallocations, require supervisory review of variances, and provide targeted training to staff on 2 CFR §200.430(i) requirements. Personnel Responsible for Implementation: Nyame-Tease Prempeh Position of Responsible Personne: Director of Accounting Expected Date of Implementation: February 1, 2026
Period of Performance Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Prospectively, UNLV Health will ensure that expenditures are charged to the gra...
Period of Performance Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Prospectively, UNLV Health will ensure that expenditures are charged to the grant within the correct period. UNLV Health will be updating the template for payroll hours to ensure only time from the invoiced month is captured. ● How compliance and performance will be measured and documented for future audit, management and performance review. The UNLV Health Finance Administrator and Accounting department will continue to review and approve the completed template along with supporting documentation, including ADP reports. Signed invoices will serve as the documentation that these were reviewed and approved. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV Health Accounting department is accountable for maintaining and approving documents. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Allowable Costs/Cost Principles Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV Health is implementing a process to require employees to certify...
Allowable Costs/Cost Principles Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV Health is implementing a process to require employees to certify time spent working on a grant. They will sign a timesheet at the end of the month. UNLV Health will then true-up the payroll costs allocated to the grant with the actual time spent for employees charged to the program on a quarterly basis. ● How compliance and performance will be measured and documented for future audit, management and performance review. Program administrators will provide the UNLV Health Finance Administrator and Accounting department with the support documentation from the EMR system. UNLV Health Finance Administrators and accounting will continue to review all support documentation for compliance and performance. The grant expenditures details are maintained and tracked via spreadsheet. Additionally, the State also conducts independent audits and UNLV Health received a clean audit from the State for this specific grant in FY24. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV Health Accounting department is accountable for maintaining and approving documents. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management staff, independent of the preparer, will review and sign off on each report. This revi...
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management staff, independent of the preparer, will review and sign off on each report. This review process will include verifying that all information is correctly entered. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured through the independent review process, where management will verify and sign off on each report to ensure accuracy. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Allowable Costs/Cost Principles Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; All relevant staff will complete targeted training on payroll cost transfer...
Allowable Costs/Cost Principles Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; All relevant staff will complete targeted training on payroll cost transfer requirements and proper process to ensure payroll adjustments are completed accurately. ● How compliance and performance will be measured and documented for future audit, management and performance review. Completion of staff training will be tracked and documented. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Period of Performance Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Training will be provided to all relevant staff on cost allowability and period of pe...
Period of Performance Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Training will be provided to all relevant staff on cost allowability and period of performance requirements. This training will reinforce that costs must be incurred within approved project period. ● How compliance and performance will be measured and documented for future audit, management and performance review. Completion of staff training will be tracked and documented. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Activities Allowed or Unallowed and Allowable Costs/Cost Principles Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN’s Office of Grants and Contracts Po...
Activities Allowed or Unallowed and Allowable Costs/Cost Principles Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN’s Office of Grants and Contracts Post-Award Management has advised the grant’s principal investigator (PI) to review expenses and avoid this issue in the future. CSN Office of Grants & Contracts Post-Award Management will continue to advise the departments that expenses associated with canceled events will be removed from the grant, unless the sponsor allows the costs to remain on the grant. ● How compliance and performance will be measured and documented for future audit, management and performance review. CSN Office of Grants and Contracts Post-Award Management will maintain communication with PIs and employees to identify any costs associated with canceled events and ensure only necessary and reasonable costs are charged to the grant. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. CSN Office of Grants and Contracts Post-Award manager is accountable for exercising oversight and responsibility. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN Office of Grants and Contracts Post-Award Management has advised the grant’s principal invest...
Reporting Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN Office of Grants and Contracts Post-Award Management has advised the grant’s principal investigator (PI) that underlying documentations must match the data reported on the Annual Performance Reports submitted to the award sponsor. The CSN GEAR UP PI and GEAR UP First Year College Advisor have refined the reporting and record keeping process to ensure accurate reporting and supporting documentation is kept in compliance with the grant. The Senior Accountant of Grants and Contracts also reviews the data before each report is submitted to the sponsor. ● How compliance and performance will be measured and documented for future audit, management and performance review. CSN GEAR UP PI and GEAR UP First Year College Advisor will continue to ensure accurate reporting and supporting documentation is kept in compliance. CSN Office of Grants and Contracts Post-Award Management will continue to communicate with PIs to ensure all reports have been reviewed for adequate and accurate supporting documentation prior to submission to the sponsor. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. CSN Program Director, who is the Gaining Early Awareness and Readiness for Undergraduate Programs (GEAR UP) Principal Investigator (PI), is accountable for exercising oversight and responsibility. GBC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; o Establishment of a formal review and approval workflow requiring secondary review by the Grants Office of participants numbers prior to submission of any financial or performance report. This will require: (1) Identification of the reporting period; (2) Review of all source documents supporting reported totals; and, (3) Mathematical reconciliation of reported figures o Training provided to grant program staff and administrative personnel on documentation standards and reporting accuracy expectations. o All corrective actions were implemented immediately upon identification of the finding and will be fully in place within 30 days of notification. The revised procedures are now standard practice for all grants reporting participant numbers. ● How compliance and performance will be measured and documented for future audit, management and performance review. o Reports may not be submitted to the pass-through entity without documented secondary review and written approval from the Grants Director or the Grant and Asset Coordinator. o Interim and final program reports will be reviewed to ensure: (1) Participant totals match underlying documentation; (2) Source documentation is retained and accessible; and, (3) Approval signatures are present prior to submission. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. o The Grants Director and the Director of Business Operations are responsible for oversight of grant compliance. NSU – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; NSU has reviewed the finding and has put additional measures in place to ensure compliance. Staff responsible for preparing reports were retrained and multi-layered quality checks have been implemented to safeguard integrity of data entered in shared databases. NSU’s multi-layered quality checks include written confirmations from staff involved in service activities and backup of documentation within NSU’s local storage to support the numbers being reported. The latter represents a move away from using a database that is accessible to multiple institutions to a centrally controlled location within NSU. This process outlined herein was implemented in August 2025 and ensures that the source documentation reconciles with reports and is available for auditing purposes. ● How compliance and performance will be measured and documented for future audit, management and performance review. To ensure compliance, NSU staff who are responsible for the program and technical reporting have reviewed and updated internal policies and procedures relating to reporting. Performance targets and benchmarks have been reestablished and will be measured at set intervals. Any errors detected will be documented and remedied. Additionally, errors will serve as the basis for continuous improvement processes and retraining as needed. These will be documented in performance reviews. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The NSU GEAR UP Principal Investigator and First-Year College Advisor Supervisor are responsible and accountable for ensuring reporting is supported by underlying records. TMCC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; TMCC reports on the number of participants for all services rendered under the GEAR UP grant through both the Interim Progress Report (IPR) and the Final Progress Report (FPR). The identified issue concerns a discrepancy between the reported participant count on the IPR and the underlying supporting records. To ensure data accuracy going forward, TMCC will implement an additional review of participant reporting. Prior to the submission of progress reports, a second technical reviewer within the GEAR UP team would verify the participant counts entered into GEARS (GEAR UP’s designated data-reporting platform) against the supporting documentation (the attendance sheet). Should a discrepancy be identified, the GEAR UP team will follow up with the individual responsible for the data entry on GEARS to reconcile the difference. This may include requesting correction of data entry errors or obtaining additional documentation to support the reported participant count, as appropriate. Additionally, attendance sign-in sheets will be collected and retained by TMCC staff to allow for direct verification prior to reporting. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured by the implementation of a second reviewer for the participant data reported through GEARS and included in the progress reporting. This review can be documented through an internal checklist, internal communication, or other appropriate records demonstrating that the participant data was reviewed and validated prior to the submission of progress reports. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Primary responsibility for accurate participant reporting will remain with the TMCC First Year College Advisor (FYCA) or other designated staff responsible for preparing grant performance reports. Responsibility for completing the secondary verification review will be assigned to a designated GEAR UP technical reviewer or program staff member who is independent of the initial data entry and report preparation. If repeat or similar observations occur, program leadership will evaluate adherence to established procedures and implement additional corrective actions, which may include staff retraining, revision of internal procedures, or reassignment of reporting responsibilities, as appropriate. UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The UNLV OSP will continue to work with PIs to ensure there is a documented review of progress reports. PIs will be expected to demonstrate review of progress reports and provide supporting documentation for data. Additionally, if reports require financial expenditures, the Office of Sponsored Programs will require validation before submission. Communication dissemination will occur twice within the academic year. ● How compliance and performance will be measured and documented for future audit, management and performance review. UNLV OSP will continue communications through Research Weekly (an internal communication newsletter) to remind PIs to ensure timely submission of progress reports and retention of records such as, lab notes, testing, populations served, activities performed, etc. to demonstrate activities supported by the grant. UNLV OSP will maintain communications with PIs to perform monitoring throughout the life of the award. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility along with the applicable Deans. UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; All participant counts reported in Interim Progress Reports will be supported by retained underlying source documentation that directly reconcile to the reported totals. Standard documentation expectations and retention requirements will be communicated to program staff. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance will be measured through pre-submission review of reported participant data against underlying records and through post-submission spot checks conducted by Program Director. Documentation supporting reported counts will be retained in the official project file and made available for future audit, management review, and internal monitoring. Evidence of reconciliation will be documented via checklists or certifications retained with the report. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Program Director WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Sponsors have determined grant practices and required reporting documentation, which have not been consistently required or expected of subrecipients. WNC will maintain its own sign-in sheets and documentation for all grant-sponsored activities to ensure compliance with overall grant requirements. The corrective action was implemented in July 2025. ● How compliance and performance will be measured and documented for future audit, management and performance review. The GEAR Up coordinator will create and maintain sign-in sheets or other documentation for every grant-sponsored activity. The coordinator will maintain records in accordance with federal and state guidance and will ensure that supporting documentation is sufficient to support the reported figures. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Final responsibility and accountability fall on the GEAR Up coordinator and grant administrator. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Matching, Level of Effort, and Earmarking Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN Office of Grants and Contracts Post-Award Management received...
Matching, Level of Effort, and Earmarking Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN Office of Grants and Contracts Post-Award Management received approval from the award sponsor to perform a budget revision to remove office space usage from the cost share. The Office of Grants and Contracts Post-Award Management also advised the Office of Sponsored Projects to avoid using unallowable cost share expenses in award applications. ● How compliance and performance will be measured and documented for future audit, management and performance review. CSN Office of Grants and Contracts Post-Award Management will continue to monitor award budgets to avoid using unallowable cost share expenses. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. CSN Office of Grants and Contracts Post-Award manager is accountable for exercising oversight and responsibility. GBC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; o GBC will standardize a cost share calculation workflow between the Grants and Business Operations departments to ensure proper calculation and review against payroll records. o GBC also will formalize written internal procedures for cost share calculation and documentation and distribute to relevant staff. o All corrective actions were implemented immediately upon identification of the finding and will be fully in place within 30 days of notification. The revised procedures are now standard practice for all grants requiring cost share. ● How compliance and performance will be measured and documented for future audit, management and performance review. o A cost share verification checklist will accompany each cost share transaction and will be retained in each year’s grant file. This internal review will confirm: (1) use of current salary data; (2) mathematical accuracy; and, (3) proper documentation support. o Grant financial reports will include documented evidence of secondary review prior to submission. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. o The Grants Director and the Director of Business Operations are responsible for oversight of grant compliance. UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The UNLV OSP has enforced a required cost share form to be completed, and will require that documentation be attached and verified before submission to the sponsor. For effort identified as cost share, a new process is currently being tested to capture it in the financial system. The cost share policy will be updated before the end of spring semester and disseminated to the campus community for immediate implementation. ● How compliance and performance will be measured and documented for future audit, management and performance review. Verifiable documentation will be required upon review/submission to be uploaded with the financial report in Workday. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility along with the Principal Investigator’s documentation. UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management will implement quarterly review of all gift accounts used for cost share to ensure that they are properly established and correctly linked to the award through a GR cost share line, which will generate the required effort certification process. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured through a review and confirmation that all cost share transactions are accurately recorded, supported, and associated with the appropriate worktags.  ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; WNC will continue its FY26 adopted internal control processes by implementing a two-step review process for all invoicing, including match verification and reporting. The assistant controller creates the invoice packet and submits it to the grant administrator for review and approval. The packet then has a secondary and final review and approval by the vice president of finance and administration. The sampled transaction occurred before internal controls were in place. Internal controls were implemented in October 2025. ● How compliance and performance will be measured and documented for future audit, management and performance review. The grant administrator maintains records of monthly invoicing reviews, including time-stamped email receipts, internal tracking spreadsheets, and Workday transactions. Workday transactions provide actuals for each invoice period, which are compared to the internal tracking spreadsheet to determine the totals to be invoiced/reported. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Final responsibility and accountability fall on the grants administrator. SA – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The spreadsheet that System Administration uses to track in-kind cost share was not correctly updated when the fringe rate changed at the beginning of the fiscal year. The Post-Award Manager will update the spreadsheet each July when the fringe rate is confirmed and run effort reports using the current salary and fringe rates. ● How compliance and performance will be measured and documented for future audit, management and performance review. The Office of Sponsored Programs will document that the fringe rate for the new fiscal year has been reviewed, and that the in-kind cost share spreadsheet was updated each July. Documentation will be included in the cost share file. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The System Administration Office of Sponsored Programs Director is accountable for exercising oversight and responsibility. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Cash Management Responses WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Western Nevada College implemented the practice of invoice review (proper segregation of du...
Cash Management Responses WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Western Nevada College implemented the practice of invoice review (proper segregation of duties) in October 2024, in which all invoices are reviewed from an individual separate from the preparer. This practice has been in place since our October 2024 grant billing period and has continued ever since. This audit finding resulted from the auditor selecting a transaction prior to WNC implementing the new procedure. All other transactions selected by the auditor were in compliance. ● How compliance and performance will be measured and documented for future audit, management and performance review. All grant invoices going forward will have a second level of review prior to drawing down or requesting reimbursement of funds. Documentation will be compiled for each grant invoice that will indicate that a second level of review has been obtained. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Vice President of Finance & Administration may be held accountable in the future if repeat or similar observations are noted. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Allowable Costs/Cost Principles Responses GBC accepts the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; o GBC maintains evidence of review and approval of the payroll expenses in questi...
Allowable Costs/Cost Principles Responses GBC accepts the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; o GBC maintains evidence of review and approval of the payroll expenses in question. GBC is very willing to enhance internal controls to provide for documented review and approval for terminated employees charged to the grant program. o GBC has strengthened internal controls over payroll expenditures charged to federal grants to ensure documented review and segregation of duties, particularly for terminated employees. o Documented evidence of review and approval will be retained within the payroll/grants file to ensure a clear audit trail. o Human Resources and Grants Accounting staff have been reminded of federal documentation requirements specific to grant-funded payroll expenditures. ● How compliance and performance will be measured and documented for future audit, management and performance review. o Quarterly internal reviews of payroll expenditures charged to federal grants, with specific review of terminated employees. o Retention of documented approval evidence in electronic grant files. o Review during annual fiscal year-end grant reconciliations. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. o The Grants Director and Director of Business Operations are responsible for oversight of grant compliance. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The UNLV OSP will continue to work with PIs to ensure there is a documented review of progress re...
Reporting Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The UNLV OSP will continue to work with PIs to ensure there is a documented review of progress reports. PIs will be expected to demonstrate review of progress reports and provide supporting documentation for data. Additionally, if reports require financial expenditures, OSP will require validation before submission. Communication dissemination will occur twice within the academic year. ● How compliance and performance will be measured and documented for future audit, management and performance review. UNLV OSP will maintain communications with PIs to perform monitoring throughout the life of the award. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility along with the applicable Deans. UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management staff, independent of preparer, will review and sign off on each report. This review process will include verifying that all information is correctly entered. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured through the independent review process, where management will verify and sign off on each report to ensure accuracy. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management Staff, independent of preparer, will review each subaward report required. The review ...
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management Staff, independent of preparer, will review each subaward report required. The review process will include verifying that all subaward information required by FFATA is correctly entered. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured through the independent review process, where management will verify the information in each report is accurate. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Pre Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Period of Performance Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Training will be provided to all relevant staff on cost allowability and period of pe...
Period of Performance Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Training will be provided to all relevant staff on cost allowability and period of performance requirements. This training will reinforce that costs must be incurred within approved project period. ● How compliance and performance will be measured and documented for future audit, management and performance review. Completion of staff training will be tracked and documented. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses TMCC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Two additional layers of review have been added to ensure that every RFR/Invoice is reviewed. On...
Reporting Responses TMCC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Two additional layers of review have been added to ensure that every RFR/Invoice is reviewed. On 4/14/25 an extra invoice review was added to Workday ensuring that they have to go through a review by someone other than the creator. During this step, the attachments including RFR and the approval email by the controller is also reviewed for accuracy. The Grant Accountant also established a log in August of 2025 that includes the Due Date, Date sent to the Controller for Approval, the Approval date and the submission date. ● How compliance and performance will be measured and documented for future audit, management and performance review. Emails documenting the review of the RFRs are kept as proof of review and saved in our files as well as Workday. The tracking document will also be made available for future review. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Grant Accountants will be responsible for ensuring that we are in compliance with the corrective actions UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV OSP does have separation of duties from the originator of the subaward to the review of the subaward agreement in entering all of the data points into Sam.gov for FFATA reporting; however, UNLV OSP will create a process document that explicitly notes this for future documentation. ● How compliance and performance will be measured and documented for future audit, management and performance review. Cross checking of the issued subaward (originator) is reviewed and entered into the federal portal by the submitter. As the federal portal requires one party to enter and submit, OSP management perceives this to be very low risk but will ensure reviews occur. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility. WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Western Nevada College implemented the practice of invoice review (proper segregation of duties) in October 2024, in which all invoices are reviewed from an individual separate from the preparer. This practice has been in place since our October 2024 grant billing period and has continued ever since. This audit finding resulted from the auditor selecting a transaction prior to WNC implementing the new procedure. All other transactions selected by the auditor were in compliance. ● How compliance and performance will be measured and documented for future audit, management and performance review. All grant invoices going forward will have a second level of review prior to drawing down or requesting reimbursement of funds. Documentation will be compiled for each grant invoice that will indicate that a second level of review has been obtained. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Vice President of Finance & Administration may be held accountable in the future if repeat or similar observations are noted. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Matching, Level of Effort, and Earmarking Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The UNLV OSP has mandated a required cost share form to be comple...
Matching, Level of Effort, and Earmarking Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The UNLV OSP has mandated a required cost share form to be completed and will require that the documentation be attached and verified before submission to the sponsor. For effort identified as cost share, a new process is currently being tested to capture it in the financial system. The cost share policy will be updated before the end of spring semester and disseminated to the campus community for immediate implementation. ● How compliance and performance will be measured and documented for future audit, management and performance review. Verifiable documentation will be required upon review/submission to be uploaded with the financial report in Workday. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility along with Principal Investigator’s documentation. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
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