Corrective Action Plans

Student Financial Assistance Program Cluster - Department of Education Federal Financial Assistance Listing #84.063 Federal Pell Grant Program P063P222212,P063P232212 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: One student was not awarded Pell assistance during the summer term as the student's FAFSA was not completed at the time the financial aid office was determining award eligibility. The student later completed the FAFSA within the award year and became eligible for a retroactive disbursement of Pell assistance; however, the financial aid office did not provide the student a retroactive disbursement of Pell. Responsible Individuals: Karrie Morgan, Director of Financial Aid Corrective Action Plan: Management will review procedures and control processes over monitoring retroactive disbursements. Anticipated Completion Date: October 31, 2024.

2024-001 Name of Contact Person: Anita Ramachandran, Interim PH Director and Victor Isler, Assistant County Manager - Successful People Corrective Action: Management promptly provided training to staff that teen clinic services are billable based on income and eligibility requirements. Proposed Completion Date: Management has already addressed this with staff.

FINDING 2024-007 Corrective Action Plan The Organization addressed the necessity of implementing a system of internal controls that would properly document the eligibility requirements set forth in the SSVF program during its most recent program audit (scope period January 1, 2022 – December 31, 2023) with the U.S. Department of Veterans Affairs. Subsequent to the program audit, the Organization instituted a corrective action plan to follow that process. In a letter dated August 21, 2024, the U.S. Department of Veterans Affairs stated and confirmed that “corrective actions were taken in response to recommendations issued by the Office of Business Oversight (OBO) in its SSVF Grant Programmatic Review.” Responsible party: Bill Kelly; Executive Director; (978) 853-7013 Anticipated completion date: August 21, 2024

Memo: Audit Findings 2023-2024 Submitted by: Karson Kent, University Registrar Date: 9/13/2024 Below is a description of and explanation for the 3 findings from the 23-24 audit pertaining to the Registrar’s office. Also included is an explanation of how the findings have been addressed, and the action that has been taking to prevent them from happening in the future. ETBU uses the National Student Clearinghouse for enrollment reporting to the National Student Loan Data System. Case 1 – Student 1 withdrew from the spring term on 1/29/2024, but withdrawal was reported as end of fall 2023. Case 2 – Student 2 withdrew from the spring term on 1/31/2024, but withdrawal was reported as end of fall 2023. Error: The enrollment report was being pulled and sent to the National Student Clearinghouse (NSC) after the census date when roster certifications and withdrawal requests, up to that point, had been processed. Students 1 and 2 both withdrew during the roster certification period, which was before the census date, but after late registration had ended. Their withdrawals were processed in the Registrar’s office before the initial enrollment report was pulled, and since they received W’s for the term, they should have been reported for the term to the NSC. In researching the finding, it was discovered that the system is set up to only include students in the enrollment report who are enrolled as of the date that the first report is pulled. This means that students 1 and 2 were never included in the initial enrollment report for spring 2024, and therefore weren’t captured on any of the subsequent of term reports that notify the NSC of enrollment changes throughout the semester. This made it look like they never attended ETBU in the spring, which is why the NSC showed their withdrawal to be the end of the fall term. Action Taken: Students 1 and 2 enrollments for the spring 2024 term have since been corrected with the NSC. Additionally, since learning how the report is set up, the Registrar has been in discussion with the Director of Financial Aid and Institutional Research, to figure out the best timeline for processing the enrollment report moving forward. It has been determined that the initial enrollment report needs to be submitted as soon as late registration ends, so that everyone who is registered for the term is captured on the report. Once the roster certification period is over, students who have been reported as not attending will be dropped, and any University withdrawal request will be processed. Once those things have been done, the Registrar will submit the first subsequent of term enrollment report to the NSC. This will ensure that any enrollment changes that have happened after registration ended up to census date get reported within the time frame needed by Financial Aid. Case 3 – Student 3 was reported as withdrawn after the fall 2023 term, but actually graduated. Error: Student 3 should have been reported to the NSC as a fall 2023 graduate, but was not included on the graduation report. In investigating it appears student 3’s degree was conferred after the fall graduation report had already been submitted, and the Registrar was not made aware of the discrepancy. Since student 3 was not reported as graduated for fall 2023, and was not enrolled in the spring 2024 term, they were considered withdrawn through the the NSC. Action Taken: Student 3’s status has been changed from withdrawn for the fall 2023 term to graduated, with the NSC. To prevent this from happening in the future, the Graduation Certification Officer has been made aware to notify the Registrar anytime a degree is conferred outside of the normal time frame, so that it can promptly be reported to the NSC. As an added measure moving forward, after degrees have been conferred for a standard term, the Records Assistant will double check all the degrees conferred to help ensure that nobody was missed.

Students in the Pell Grant Verification Status (PGVS) file will be reviewed by a Financial Assistance Advisor for Pell and another Financial Assistance Advisor for Verification to make sure all appropriate flags are set correctly in the system. Once this review is complete, Pell will be re-originated. If students persist in the PGVS file, a help desk ticket will be filled with our Information Technology department to investigate why the record is still showing as not verified. This new review process will provide additional oversight in the verification process.

The College acknowledges that a submission error occurred in Spring 2023, resulting in several students not being included in the routine semester enrollment submissions to the National Student Clearinghouse (NSC). Beginning in Spring 2024, our Institutional Research department initiated a comprehensive process to resubmit corrected enrollment files to the NSC, covering Spring 2023, Summer 2023, and Fall 2023. In collaboration with NSC, we followed their established process to rectify the error, which required reloading each submission one at a time in succession from the original submission with the error. This process caused delays in our subsequent submissions until the corrections were fully completed. To prevent recurrence, we have implemented enhanced checks and controls prior to each submission to review the file and file size to ensure the correct number of students are submitted to NSC. Additionally, all submissions post-Spring 2023 have been reviewed, and we have confirmed that this was an isolated incident.

Finding Summary: One instance was identified in which the student was over-awarded Federal Pell assistance. The Watertown location does not use the auto package tool within Anthology for awarding students; rather, awarding student assistance is a manual process. The incorrect line item was read on the PELL chart resulting in the student being over-awarded Pell assistance in the summer of 2023. Responsible Individuals: Lauren Svanda, Director of Financial Aid Corrective Action Plan: When implementing the FAFSA changes for 2024, the SIS was configured to utilize the Auto Packaging function for the Watertown location which significantly reduces the likelihood of a student being awarded the incorrect amount of PELL. After each student is Auto Packaged, it is reviewed to ensure accuracy of the PELL calculation. Anticipated Completion Date: Resolved – Spring 2024

The Housing Manager will complete quality control file reviews from a random sampling of applicant files to ensure that they contain all required documentation for eligibility determination. An external agency will be hired to conduct a complete a full file audit of active files.

Planned Action: Family Pathways Food Access and Finance staff will communicate the audit finding to the appropriate authoritative TEFAP bodies: the Minnesota Department of Human Services, as administrator of Minnesota’s TEFAP program and issuer of Minnesota’s TEFAP Policy and Operations Manual, as well as Second Harvest Heartland, as pass-through agent and contractor of TEFAP food distribution. In addition to communicating the audit finding, Family Pathways will confirm what authorities exist for Family Pathways, as a TEFAP provider, to implement additional internal controls, including but not limited to: modifying current DHS TEFAP forms and applications, and/or requiring additional client application forms. Family Pathways would like to note that the current DHS TEFAP Policy and Operations Manual 2023, effective for the audit period indicated above, states that “additional eligibility criteria cannot be imposed on participants” and that “TEFAP Providers agree to make it as easy as possible for those in need to access food.”

Recommendation: We recommend that a review is implemented which compares enrolled credits to Pell award to ensure all Pell funds are awarded at proper amounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: With our new student information system, Anthology Student, there are regulatory controls in place that ensure that the Pell awards are awarded at proper amounts per enrolled credits. All undergraduate students are packaged Standard Academic Year (SAY) beginning with the 2024-2025 academic year. This packaging method will ensure that all Pell eligible students will receive their entire Pell award amount for the year. Name(s) of the contact person(s) responsible for corrective action: Andrea Padilla-Rosas Planned completion date for corrective action plan: August 2024

Federal Program Title: Student Financial Assistance Cluster ALN: 84.063 Recommendation: We recommend the University review its current procedures for awarding Title IV funds to ensure only eligible students are receiving funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Additional staff training has been provided to R2T4 staff regarding Pell eligibility for students who enroll in courses on census day and withdraw shortly thereafter. Staff have been instructed and procedures updated to review the faculty response regarding participation in a withdrawn course before offering Pell prior to completing the R2T4 calculation. Name(s) of the contact person(s) responsible for corrective action: Lauren Krigbaum, Associate Director of Systems & Processing. Planned completion date for corrective action plan: September 30, 2024

Section III – Federal Award Findings and Questioned Costs 2024-001-Eligibility: Rent Calculation Corrective Action: The North Providence Housing Authority will be creating a check list which will include Income Verification as part of the participants file to be used for examinations, and reexaminations of income. This check list will be completed by the Housing Authority staff member, signed, and dated, showing that all required documents have been obtained and used for a successful processing of the tenants rent. Additionally, due to being a small housing authority, with only one HCV staff member, we have hired an HCV Assistant to help the HCV Coordinator in obtaining all information needed to comply with HUD’s regulations. Planned Implementation Date of Corrective Action: Immediately Planned Implementation Date of Corrective Action: Eileen Reyes/Michael McMahon/Cheryl Lonardo

The Financial Aid (FA) department is taking additional steps to determine the amount of Federal Direct Loans a student is eligible to receive based on their academic classification, ensuring the loan amounts align with the annual limits set forth by the U.S. Department of Education, which are contingent on the student's academic progress and dependency status. Monitoring will take place by FA to review student loans prior to disbursement to ensure awards are following Department of Education guidelines. Completion date: This process has been implemented with the start of the Fall 2024 semester.

The Financial Aid (FA) department is verifying the cost of attendance (COA) by crossreferencing the student's enrollment status, residency status, and any special circumstances before any financial aid is disbursed. FA is also monitoring changes in a student's enrollment status, housing arrangements, awarding or other factors that could affect their COA and running an "Over Award Report" from Campus Cafe throughout the semester. Completion Date: This process has been implemented with the start of the Fall 2024 semester.

MANAGEMENT’S CORRECTIVE ACTION PLAN CHICAGO THEOLOGICAL SEMINARY For The Year Ended June 30, 2024 Finding 2024-001 Verification Federal Agency: U.S. Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing #: 84.268 Questioned Costs: None Corrective Action: We agree with the auditor’s comments, and actions stated in the recommendation. The Seminary will be amending its Policies and Procedures to incorporate required language to be in compliance. Furthermore, the Seminary has hired a consultant with 15 years of experience managing Federal Awards. In partnership with the consultant, the Seminary will implement additional controls to ensure application of new policies and procedures. Contact Person: Michele Carr, Controller Anticipated Completion Date: October 31, 2024

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Recommendation: We recommend the University work with the third-party to determine why the data is not transferring correctly to NSLDS. We further recommend the University complete spot checks of enrollment statuses to NSLDS, particularly for those students who withdrew. Planned Corrective Action: An internal SSRS report for official and unofficial withdrawals which accurately reflects withdrawn students remains available to the WBU offices of Financial Aid and the Registrar for verification as part of the planned corrective action. The custom NSC reporting tool(s) will continue to be updated to make sure the correct combination of fields and corresponding data sources are reported as accurately as possible. WBU will continue to work with NSC to mitigate issues related to data not transferring correctly between NSC and NSLDS. § A field-by-field analysis plus any needed corrections to the queries will be performed. • By default, term “W” withdrawals are reconsidered by the updated tool each time a report is generated for NSC. • Some date fields have been corrected that were previously misunderstood by the custom tool’s historical authors. • Post-submission error corrections by registrar staff via NSC’s website are spot-checked by Information Technology when requested. • If certain data issues cannot be resolved satisfactorily via NSC alone, then corrective measures via NSLDS directly may be considered. • The PowerCampus 9.1.2 baseline product’s NSC reporting tool was determined to be insufficient for timely and accurate reporting to NSC with WBU’s current data on several counts. WBU has upgraded the PowerCampus system to version 9.2.3 and will continue to work towards a solution for the baseline reporting tool with the upgraded system. • Some of the recurring data updates needed before running the PC baseline tool, are still being run periodically as a source data benefit for the custom tool. Person Responsible for Corrective Action Plan: Cagan Cummings, Chief Information Officer Anticipated Date of Completion: Ongoing

Finding 2024-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.

Action taken in response to finding: The employee responsible for eligibility processing and verification is new to the process. The employee attended all of the trainings provided by CDE prior to conducting verification. The employee misinterpreted “net wages” vs “gross wages” on the paystub, which led to this discrepancy. The household had listed net wages on their application this year and prior years. The student’s status was corrected and backdated to the verification response date. April and May 2024 claims are not affected by overpayment due to the student’s status having been updated before claims were sent to the state for payment. USDA disregards overpayment of reimbursement if the amount does not exceed $600 annually (Section 119c). Since the amount is not over $600, CDE is not required to collect the discrepancy. The District will move into 100% Community Eligibility Provision (CEP) for SY 2024-2025, and continuing for up to 5 consecutive years following enrollment into the provisional program. CEP does not require income application submittal, thus does not host an annual verification certification because data is received solely through Direct Certification reports provided by CDE monthly. Staff responsible for eligibility determination will continue to take the online trainings from CDE and our Nutrition Software annually as required. Name(s) of the contact person(s) responsible for corrective action: Kari Jacobs Planned completion date for corrective action plan: 5/2/2024

Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The reason that R214 were done late/inaccurately was due to an employee who was new to the position and instead of seeking assistance in a timely manner, waited until the prior retired Director of Student accounts was contracted in to assist. This employee was transferred from enrollment department oversight and then transferred to business office oversight mid-year. Neither department could provide the necessary management of this position and that is when they reached out to contract back the former Director of Student Accounts. Our only other trained R2T4 employee left LPU in Spring 24 and due to staffing challenges with FAFSA Simplification, we could not get someone new trained in time. We have been working with a consulting firm, JM Solutions, and with consultants' input, we are restructuring the financial aid and Student Accounts department to fall under one direct oversight. LPU created an Associate Vice President of Enrollment Services who oversees FinancialAid, Student Accounts and Registrar. Underthe Associate VP, there is a new Director of Student FinancialServices (this combined role is the Director of Financial aid and Student Accounts). Going forward R2T4 will be done on the COD system per consultants' recommendation. Currently the Director of Student Financial Services is being trained on R2T4, and they are seeking to hire a fulltime position of a Financial Aid processor who will be trained on R2T4 as well. For now, the Associate VP and Director of Student Financial Services will be working together to ensure R2T4 are completed according to regulations, with additional oversight by consultants throughout the academic year. Person Responsible for Corrective Action Plan: Amber Burnett, Associate Vice President of Enrollment Services and Angel Cavazos, Director of Student Financial Services Anticipated Date of Completion: At this time oversight and changes are in place for the R2T4 process

The Bethlehem Central School District appreciates the requirements of 2 CFR Section 200.213. The District's recent review of vendors indicated that there weren't any instances of ineligibility for participation in Federal assistance programs. To ensure formalized compliance, the District is updating procurement procedures which will highlight that the Purchasing Agent will check the SAMS Debarment and Suspension website on an annual basis. Results from this annual check will be logged and shared with both the Treasurer and Chief Business and Financial Officer and will be available for access by auditors or the public. Ineligible vendors, as noted on the SAMS website, will be removed from the District's financial management system. Implementation Date - Effective immediately.

The District should only include actual costs, not budgeted costs, on the expenditure reports filed with the Illinois State Board of Education. The District should also ensure that the expenditure reports filed with the Illinois State Board of Education are reconciled with the general ledger accounts of the District prior to submission. The District will ensure that expenditure reports only include eligible expenditures going forward. The District will take the necessary steps to reconcile the expenditure reports with the general ledger accounts before submitting to the Illinois State Board of Education.

The District should ensure that the expenditure reports filed with the Illinois State Board of Education are reconciled with the general ledger accounts of the District prior to submission. The District will take the necessary steps to reconcile the expenditure reports with the general ledger accounts before submitting to the Illinois State Board of Education.

Student Financial Assistance Cluster – Assistance Listing No. 84.007. Recommendation: We recommend the University review their FSEOG awarding policy and procedures to ensure FSEOG is awarded to students with the lowest expected family contributions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Financial Aid updated our auto packaging policy. Name(s) of the contact person(s) responsible for corrective action: This was a part of our aid year rollover process and planning. Planned completion date for corrective action plan: April 2024

Student Financial Aid Cluster: Federal Pell Grant Program – Assistance Listing 84.038 Recommendation: We recommend the College review its current procedures for awarding Title IV funds and implement any changes necessary to ensure federal funds are awarded and disbursed in accordance with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finding was isolated to less-than-half-time Pell recipients. These recipients will be processed through the auto-packing process and then will undergo a secondary manual review prior to disbursement. Name(s) of the contact person(s) responsible for corrective action: Laura Hughes and John Bender Planned completion date for corrective action plan: Immediate Implementation

To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2024 The findings from the April 30, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2024.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but we now have it implemented at all clinic sites. The purpose of this department is to make sure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. When adding or updating charges with the GFH Fee Schedule, a new process has been implemented to run a report “CPT’s in Multiple Groups” to verify the charge (CPT Code) is not duplicated within another CPT group. This report will be run by the Billing Director and reviewed for accuracy. If there are any question regarding this plan, please e-mail Amanda Vaughan at Amanda.Vaughan@GenesisFH.org. Sincerely, Amanda Vaughan (electronically signed 10/10/2024) Amanda Vaughan Chief Financial Officer