Corrective Action Plans

Name of contact person: Katie Langan Corrective action: With respect to the finding relating to program length issues, the College agrees with this finding and will make appropriate changes to ensure that the NSLDS records for program length are based on years, correcting the earlier issue of basing program length by weeks. With respect to the program change date record retention issue, the College agrees with this finding and will take appropriate actions to correct this issue. These actions will include retraining of staff to reinforce the necessity of retaining the records, providing adequate secure storage facilities for paper records and conducting regular quality control exercises to ensure that this issue does not re-occur. Proposed completion date: June 30, 2024

Finding 2023-002 Eligibility Auditee's Response and Planned Corrective Action The Authority has had staff and consultant turnover during the 2022 audit period. Additionally, the eviction moratorium and lasting effects from the COVID-19 pandemic have resulted in delayed or nonexistent response from tenants regarding obtaining the necessary documentation for eligibility requirements. The Authority has evidentiary documentation supporting their attempts to obtain the required documents from the tenants, including certified letters. The courts suspended evictions during the eviction moratorium that resulted from the COVID-19 pandemic, which includes evictions for nonpayment and noncompliance. The Authority has been working with legal counsel on these matters and continues to pursue this vigorously. The Authority's staff and consultants have been diligently working to implement improvements to the administrative systems related to recertifications. Additionally, the Authority has put in place a checklist for occupancy documents that are reviewed during recertification and when processing new tenants that must have annotations, check mark, that confirm that all required papers are in compliance and signed where appropriate. This check list will have at least one redundant review by the Authority's directors or designee. Planned Implementation Date of Corrective Action: March 2024 Person Responsible for Corrective Action: Keith Burrell, Executive Director

TRIO Upward Bound has new leadership from the Director up to the Vice President. The new Director has already implemented a new set of protocols to verify all eligibility markers are met. The Director's supervisor, the Dean of Equity and Inclusion, will conduct a spot check twice annually. Contact person(s) responsible for corrective action: Jimmie Sanders, Director TRIO Upward Bound and Desiree Anderson, Dean of Equity and Inclusion. Anticipated Completion Date: Immediate

Contact Person: Interim Executive Director Fred Bazemore Corrective Action: The Organization agrees with the finding and is working to establish a clear understanding of the grant eligibility requirements with the grant coordinators to ensure eligibility requirements for the Uniform Guidance are followed. Anticipated Completion Date: This corrective action will be implemented by June 30, 2024.

Finding Summary: Change, Inc. has an internal control process designed to review and sign the eligibility forms, but the controls did not operate as designed. Personnel at Change Inc. Were unable to produce documentation supporting the review of participant files for participant eligibility. Responsible Individuals: Jill Johnson, Associate Director Corrective Action Plan: We are working to formalize this process by creating a written participant file review policy and procedure. Anticipated Completion Date: March 31, 2024

Contact Person: Cynthia McCarthy, Director of Financial Aid Corrective Action: For the 2023-2024 academic year Cost of Attendance Budgets were reviewed and tested to correct any miscalculations and omissions. Pell Budgets were updated to correctly differentiate program tuition and fees. Testing for 2024-2025 academic year has been updated and reviewed to accurately calculate Cost of Attendance Budgets. In some of the findings it was later found that due to changes made in the student’s record, the record should have run through the dynamic redetermination process to update the budget. The staff has been retrained in this process. The process for summer periods of enrollment has been reviewed and revised to flag students who initially applied and or registered for summer classes and subsequently did not register or dropped the classes during the add/drop period and the summer period of enrollment remained thereby calculating a Cost of Attendance for summer. Anticipated Completion Date: January 3, 2024

Ineligible Programs Planned Corrective Action: Additional training regarding program eligibility has been conducted with the Processing Team. Previously unknown functionality to designate a program as being ineligible for Title IV aid in the Colleague administrative system was identified and implemented. Title IV funds can no longer be disbursed for programs marked as ineligible. Person Responsible for Corrective Action Plan: Bryan Taylor, Associate Director of SFS Processing Anticipated Date of Completion: February 2024

2023-004 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN No. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Condition: We examined 40 student files and we noted one student was not properly awarded their Pell grant. We consider this condition to be an instance of noncompliance relating to the Eligibility compliance requirement. Management Response: This was a student transferring from a college that had closed (Lincoln College) the Financial Aid staff did not calculate new PELL eligibility with the Eureka College COA and awarded Pell from the wrong matrix on the Pell payment chart. Corrective Action Plan: All pell awards are now being offered based on correct COA and Pell Grant matrix with the Eureka costs. Responsible Person: Tim Marten, Director of Financial Aid Implementation Date: Spring 2024

2023-003 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN No. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Condition: We examined 40 student files and we noted 3 out of 40 students were not properly awarded Direct Loans. One of these students was improperly awarded subsidized loans and instead should have received unsubsidized loans. Additionally, the College did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 1 of the 40 students in the sample (2.5%). We consider these conditions to be instances of noncompliance in internal control over compliance relating to the Eligibility compliance requirement. Management Response: Cost of Attendance (COA) calculations were not updated to ensure ratio of subsidized versus unsubsidized loans were correct. It looks like awards were not being recalculated as additional need based aid was added to awards for these students. Corrective Action Plan: New financial aid software (JFA) was implemented for the 2023-2024 academic year. A component of this software is a compliance check for COA and other issues. The compliance check for over awards should catch instances of the wrong sub/unsub ratio in the future. Responsible Person: Tim Marten, Director of Financial Aid Implementation Date: Fall 2023

2023-002 Eligibility Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and ALN: Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P130272 (7/1/2022 - 6/30/2023), P268K130272 (7/1/2022 - 6/30/2023) Contact Person: Jean McDonald Rash, AVP Enrollment Services, 848-932-2605 Corrective Action: In order to correct the issue of students being awarded in excess of their cost of attendance, a weekly report has been developed to capture any student whose financial aid, from any source, exceeds the assigned cost of attendance. The Financial Aid Processing team in University Enrollment Services receives and resolves the issues in the report weekly to ensure that students are not awarded in excess of their assigned cost of attendance. In order to correct the issue of the incorrect calculation of the cost of attendance components, a testing plan has been developed that includes manually checking each program cost of attendance prior to signing off for production aid packaging. The script that caused the cost of attendance components to be doubled was corrected prior to the 2023-2024 aid year. Anticipated Completion Date: Completed

CContact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures to ensure all students who receive a free or reduced meal have a current and accurate application on file. Completion Date – December 29, 2023

Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures for verifying free and reduced applications. Completion Date – December 29, 2023

The City has taken action by updating the procedures to now include a requirement for attaching the suspension and debarment verifications as part of the documentation process.

2023-006 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth and Adult Activities participants. Action Taken: The Board’s Youth Liaison monitors the In School and Out of School Youth eligibility every six months following the policy and procedures referencing the CF200. The Board’s Youth Liaison reviews the Youth files to determine if the Youth meets the eligibility criteria for the Youth program. Her monitoring is reviewed every six months during the State Audit. The Board will review her monitoring along with copies of the completed registrations from the Board’s subrecipient which determines which program the youth (Youth In or Youth Out) is eligible for the fiscal year. The Board will state that they have reviewed the eligibility perimeters and these were followed by the subrecipient and verified by the Youth Liaison. For the Adult Program, the Board has implemented internal controls to ensure each applicant completes the applications and to determine if they are eligible for the programs the Board offers. Our Business Services Manager reviews each application taken by the Board’s Career Services Coordinator and ensures they are in the correct program by the application.

Finding 2023-001 Personnel Responsible for Corrective Action: Senior Vice President, Student Experience – Joseph Sallustio Anticipated Completion Date: March 2024 Corrective Action Plan: The University has completed its implementation of Anthology, a student information system, during the 2023-2024 fiscal year. The new system has several built in features that are supplemented with internal controls to ensure financial aid is awarded correctly. The system automatically awards the student at full-time, the awards are then confirmed through a review process before sending out the award notification, and again before payment. The system compares the full-time award status with the actual enrollment and if they do not match the student will fail for payment and we will revise the award.

At the beginning of FY2024, under the terms of PHA's Recovery Agreement with HUD, PHA's consultants conducted PIH internal QCs and staffing assessments. As a result of those findings, PHA has reorganized and increased the PHA staff, with a new Public Housing Manager. Staff are being fully trained regarding eligibility determinations and rent calculations, checklists are being developed and regular internal QCs performed, with an objective of full compliance by the end of calendar year 2024.

The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Section 8 program compliance. Following an internal SEMAP QC review in July 2023, staff have been retrained and certification/recertification checklists have been created. Initial and annual recertifications are currently being conducted in accordance with the applicable HUD regulations and guidance and will be internally reviewed during a July 2024 SEMAP QC review .

FINDING 2023-006 Subject: Title I Grants to Local Educational Agencies – Internal Controls Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A190014, S010A200014, S010A210014, S010A220014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility, Reporting, Special Tests and Provisions - Assessment System Security Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Terri Chance Contact Phone Number and Email Address: 219-924-4250 tchance@griffith.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Griffith Public Schools will be developing, implementing, and documenting, a system of internal controls, including policies and procedures that provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Anticipated Completion Date: June 30, 2025

FINDING 2023-004 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.559 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Contact Person Responsible for Corrective Action: Tiffiny Ulman Contact Phone Number and Email Address: 219-924-4250 tulman@griffith.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Establish post award internal controls surrounding grant management including, but not limited to, Eligibility. Anticipated Completion Date: 3/5/2024

U.S. Department of Health and Human Services Bullhook Community Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2023-001 Health Center Program Cluster Recommendation: Management should review their policies and procedures with the personnel responsible for providing the sliding fee discount and for ensuring that documentation is maintained to support the eligibility of sliding fee discount. We also recommend that management implement, monthly or quarterly, a self-audit process of newly approved sliding fee discount recipients and their associated patient record. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Staff were retrained on sliding fee policy and procedure. Going forward frequent audits from the sliding fee applications received and entered will be conducted to ensure that proper documentation is maintained. Name(s) of the contact person(s) responsible for corrective action: Kyndra Hall, CEO Planned completion date for corrective action plan: June 30, 2024 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kyndra Hall, Chief Executive Officer at (406) 395-6904.

Management Response/Corrective Action Plan: Before the Nutrition Director submits the claim, the Business Manager will review the claim with the Nutrition Director.

Management Response/Corrective Action Plan: Management should ensure all documentation is filed and maintained after it is received.

Management Response and Corrective Action Plan: The College runs weekly reports from the Ellucian Colleague system to identify students with CFlags and comment codes for loan limits. While reviewing the report if a student has comment codes for loan limits, the staff member running the reports will research and assign the issue to the appropriate Financial Aid Assistant Director to adjust the loan accordingly. For the student identified, the loan limit was calculated incorrectly in the Colleague system and the student was awarded a federal direct loan that exceeded their maximum total aggregate outstanding loan debt by $2,500. It is our belief this was not an issue of identifying the CFLAG, it was human error with reduction of loans. To correct the issue this student was awarded institutional aid to cover the amount loans were reduced. To confirm that no other student’s were impacted by a similar issue, a CFLAG full audit report was run for 2022. The report was reviewed to determine if there were any other students that had an aggregate loan limit issues. It was confirmed that this student was the only issue. The Office of Financial Aid will be enhancing the rules in our Colleague system to prevent disbursement if the Loan Limit CFlag has not been fully resolved. Staff will also be trained to not solely rely on Colleague’s Loan information and to seek verification of loan limits directly from NSLDS. OFA member that reviews loan limits will need to include the students NSLDS record in the students folder, confirmation of and loan amounts, and detailed description of adjustments. A monthly audit will occur by an Associate Director or the Director to confirm accruary and completeness. Scheduled Date of Completion: 4/15/2024 Contact person responsible: Katrina Bennett, Director of Financial Aid

Person(s) Responsible for Implementing the Corrective Action: Jenny Holden Senior Director, Grants and Community Development Corrective Action Planned: Management has implemented a process to identify any payment requests connected to internal personnel and escalate these requests for director approval prior to payment being issued. Anticipated Completion Date of Corrective Action: Management has implemented the corrective actions during FY 2024.

Finding 2023-001: Student Financial Assistance Cluster – Eligibility – Award Limits Name of Contact Person: Alice Herrick, Director of Fiscal Operations; Ryan French, Director of Financial Aid Corrective Action Plan Introduction: This Corrective Action Plan addresses the significant deficiency identified in the audit regarding the review of student enrollment data prior to loan approval. The deficiency resulted in one noted student receiving a federal loan disbursement above their annual eligibility limit, and two students who each received a federal loan disbursement below their annual eligibility limit. We acknowledge the issue and have implemented immediate corrective measures to rectify the situation and prevent recurrence. Root Causes Analysis: The deficiency stemmed from two main factors: a. Limitations of PowerFAIDS: The software lacks automated quality control mechanisms to prevent overawarding or overdisbursement. Additionally, the software’s database design poses a challenge due to the “one-to-many” relationship of Periods of Enrollment (POE), making automated packaging algorithms which address this deficiency impossible. b. Staff Awareness: Financial aid staff were unaware of PowerFAIDS' limitations and lacked clear guidance on necessary quality control procedures. Immediate Corrective Actions Implemented: In response to the deficiency, the following actions have been taken: a. Manual Quality Control Procedure: A manual review process has been established prior to each semester's disbursement date. This process includes verifying student enrollment data and identifying discrepancies between self-reported class levels (PF: "F-YR-SCHOOL") and official class progression (PC: "academic_class_level", PF: "POE-YR-SCHL"). b. Repackaging and Communication: Students with verified discrepancies in class levels are repackaged accordingly and updated financial aid offer letters/emails are sent to notify students of changes and request their consideration. Confirmation of Effectiveness: A thorough review of the 2023-2024 academic year data confirms that no current students have been awarded or disbursed above their annual eligibility limit, validating the effectiveness of the implemented quality control procedure. Future Mitigation Strategies: To further mitigate the risk of noncompliance and reduce manual review time, the following strategies will be implemented: a. Dynamic Custom Field in PowerFAIDS: Proposing the creation of a dynamic custom field (e.g., “PC_ACL_Progression”) that updates student class levels via API integration with PowerCampus. b. Automated Packaging Rule: Developing an automated packaging rule within PowerFAIDS based on the dynamic custom field to identify Year In School (YIS) mismatches and trigger necessary repackaging. This rule will incorporate the YIS Mismatch quality control function and algorithm, reducing the time commitment necessary for manual review. Timeline for Implementation: While a current manual process is in place, the proposed future mitigation is forthcoming. a. Manual Quality Control Procedure: This procedure was put into effect by Financial Aid staff on November 16th, 2023, and was successfully implemented prior to Spring 2024 disbursement. All current disbursements of Federal TitleIV aid have been made in accordance with U.S. Department of Education criteria. b. Future Mitigation: The proposed dynamic custom field and automated packaging rule will be developed and implemented within the next academic year to streamline the quality control process and enhance compliance measures. Conclusion: Maine Maritime Academy is committed to ensuring compliance with U.S. Department of Education regulations and providing accurate and appropriate financial aid awards to students. The corrective actions outlined in this plan address the deficiencies identified in the Uniform Guidance audit and aim to prevent similar issues in the future. We appreciate the audit findings and remain dedicated to continuous improvement in our financial aid procedures. Name of Contact Person: Alice Herrick, Director of Fiscal Operations; Ryan French, Director of Financial Aid Corrective Action Plan: The Academy will review current procedures related to awarding Unsubsidized and Subsidized loans and implement additional review procedures to ensure awards to students are appropriately within limits set by the Department of Education. Planned Completion Date: June 2024