Corrective Action Plans

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Return of Title IV (R2T4) Calculations Planned Corrective Action: The Financial Aid Office (FAO) has reviewed the R2T4 process and implemented additional procedures to strengthen the accuracy and documentation of withdrawal calculations, particularly for students enrolled in module-based programs. T...
Return of Title IV (R2T4) Calculations Planned Corrective Action: The Financial Aid Office (FAO) has reviewed the R2T4 process and implemented additional procedures to strengthen the accuracy and documentation of withdrawal calculations, particularly for students enrolled in module-based programs. The Financial Aid Office (FAO) has implemented the following enhanced procedures: • The internal R2T4 policy document has been reviewed for accuracy to ensure that all required steps are noted. • R2T4 calculations involving module enrollment, withdrawal exemptions, or Post-Withdrawal Disbursements will receive a second-level review before the calculation is finalized and funds are returned to the Department of Education. • The FAO will maintain a tracking process to monitor R2T4 calculations, required return amounts, and return deadlines to ensure that required returns are completed accurately and within the applicable federal timeframe. • The Financial Aid counselors will receive refresher training on R2T4 requirements, with particular emphasis on withdrawals from module-based programs, the 49% withdrawal exemption, Post-Withdrawal Disbursements, and determining which modules and aid must be included in the calculation. The Director of Financial Aid will periodically review a sample of completed R2T4 calculations to verify compliance with federal requirements and the institution's procedures. Any errors identified through this monitoring will be corrected promptly and used to determine whether additional staff training or procedural changes are necessary. Person Responsible for Corrective Action Plan: Cindi Patterson, Director of Financial Aid Anticipated Date of Completion: October 1, 2026
Need Analysis Planned Corrective Action: North Greenville University recognizes that this finding represents a recurrence of the prior-year need analysis finding. Although procedures were implemented after the prior finding, the current-year audit identified a specific gap in monitoring changes to t...
Need Analysis Planned Corrective Action: North Greenville University recognizes that this finding represents a recurrence of the prior-year need analysis finding. Although procedures were implemented after the prior finding, the current-year audit identified a specific gap in monitoring changes to the Cost of Attendance (COA) and their impact on subsidized loan eligibility. The enhanced procedures described below address this risk by identifying instances where a student's subsidized loan exceeds remaining financial need after changes to COA. The Financial Aid Office (FAO) has implemented the following enhanced procedures: • The FAO has developed a targeted PowerFAIDS report to identify students whose subsidized loan award exceeds their remaining financial need. The report will be used as a specific exception report to identify potential subsidized loan over-awards resulting from changes to a student's financial aid eligibility. • The targeted PowerFAIDS report will be reviewed as part of the FAO’s pre-disbursement compliance process. Student records identified by the report will be reviewed to determine whether a change in COA, enrollment, or other financial aid resulted in a subsidized loan over-award. • The Financial Aid staff responsible for packaging, COA adjustments, loan adjustments, and disbursement review will receive additional guidance regarding the relationship between COA, remaining need, and subsidized loan eligibility. Staff will be specifically instructed to reevaluate loan eligibility when changes to housing status or other components of COA affect a student's remaining need. The PowerFAIDS exception report identifying subsidized loan awards that exceed remaining financial need will be reviewed each term and as part of the pre-disbursement review process. Additionally, the FAO will monitor significant changes to COA, particularly housing status changes, to ensure that changes in need are appropriately reflected in federal loan eligibility. Any exceptions identified will be reviewed and corrected promptly. Documentation of the review and any resulting adjustments will be retained as evidence of the control being performed. Regarding the one locked student record identified, PowerFAIDS currently has a task that identifies students in DR (Data Review) status and assigns the record to a Financial Aid counselor for review. As an enhancement to this existing control, counselors will verify the student's ISIR processing status and confirm that applicable ISIR fields are unlocked when an updated ISIR is expected. This additional verification is intended to ensure that a subsequent ISIR can successfully upload and update the student's financial aid record. Counselors will review the student's record to determine whether the locked ISIR prevented updated FAFSA information from being received or processed and will take the appropriate corrective action before finalizing the student's eligibility. As part of the DR review, counselors will verify that the student's most recent ISIR has processed correctly and that applicable federal aid eligibility, including Pell Grant eligibility, has populated appropriately. If the student's record remains in DR because of an ISIR processing issue, the counselor will resolve the issue and document the review before the student's aid is finalized. Person Responsible for Corrective Action Plan: Cindi Patterson, Director of Financial Aid Anticipated Date of Completion: October 1, 2026
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will review internal control policies to ensure monthly replacement reserve deposits are made in accordance with HUD requirements. Contact Persons Responsible: Earl L. Henderson, Jr., President of Bo...
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will review internal control policies to ensure monthly replacement reserve deposits are made in accordance with HUD requirements. Contact Persons Responsible: Earl L. Henderson, Jr., President of Board of Directors Billie Williams, President of Active Real Estate Management Completion Date: Open
The City will work on a formal process for tracking all federal grants.
The City will work on a formal process for tracking all federal grants.
The City will work on a formal process for tracing all federal grants.
The City will work on a formal process for tracing all federal grants.
FINDING 2026-003 Name of Responsible Individual: Courtney Thompson-Ballard, Director of Financial Aid Corrective Action: Upon review of the data that was reported inaccurately, it was determined that updating this data point, the earliest enrollment date for the award year, via a systems integration...
FINDING 2026-003 Name of Responsible Individual: Courtney Thompson-Ballard, Director of Financial Aid Corrective Action: Upon review of the data that was reported inaccurately, it was determined that updating this data point, the earliest enrollment date for the award year, via a systems integration was not the most reliable way to update the value. An internal system within the Financial Aid Management System (FAMS) will be used to populate this date going forward. The Financial Aid Office will add an additional quality check post origination as well to ensure accuracy. Anticipated Completion Date: September 30, 2026
FINDING 2026-002 Name of Responsible Individual: Alex Putzer, AVP for Business & Finance Corrective Action: The University has implemented enhanced controls over Federal Pell Grant cash draws to ensure compliance with federal cash management requirements. The University will maintain an approximate ...
FINDING 2026-002 Name of Responsible Individual: Alex Putzer, AVP for Business & Finance Corrective Action: The University has implemented enhanced controls over Federal Pell Grant cash draws to ensure compliance with federal cash management requirements. The University will maintain an approximate $50,000 cushion between cumulative eligible financial aid disbursements and cumulative funds drawn through the G5 portal. Prior to each draw, cumulative financial aid awarded and recorded in the University’s general ledger will be reconciled to cumulative G5 draws to ensure funds requested do not exceed eligible disbursements. Additionally, the AVP for Business and Finance will review and approve each draw prior to submission to provide an additional level of oversight and ensure continued compliance with applicable federal cash management requirements. Anticipated Completion Date: September 30, 2026
Finding 2026-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action The Board of Directors will conduct board meetings as frequently as needed to allow them t...
Finding 2026-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action The Board of Directors will conduct board meetings as frequently as needed to allow them to fulfill their responsibilities and/or obtain counsel if meetings cannot be scheduled/held. Anticipated Completion Date September 30, 2026
SECTION 5 – CORRECTIVE ACTION PLAN Finding 2026 – 001: Restatement to Net Position Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets that were improperly recorded in prior years. Plan: The Authority will implement internal con...
SECTION 5 – CORRECTIVE ACTION PLAN Finding 2026 – 001: Restatement to Net Position Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets that were improperly recorded in prior years. Plan: The Authority will implement internal controls to properly record capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completion: Fiscal Year 2027 Name of Contact Person: Lisa Mittel, Assistant Director of Management Services Management Response: Management recognizes the finding and has implemented a tracking system to document historical capital assets, register adjustments, and record future acquisitions.
Corrective Action Planned: The Organization has implemented revised procedures to strengthen controls over the allocation of payroll costs charged to federal awards. Effective January 1, 2026, payroll costs charged to grants are calculated directly from employee labor hours recorded in the Organizat...
Corrective Action Planned: The Organization has implemented revised procedures to strengthen controls over the allocation of payroll costs charged to federal awards. Effective January 1, 2026, payroll costs charged to grants are calculated directly from employee labor hours recorded in the Organization's timekeeping system and are allocated using each employee's applicable rate of pay. Under the revised process, payroll allocations are prepared using detailed labor reports that support the hours charged to each grant. Supporting documentation is maintained for each grant allocation and is reviewed monthly prior to invoicing or charging costs to the grant. The review process includes verification that labor hours charged to the grant agree to timekeeping records and that payroll costs are calculated using approved pay rates. Management believes these revised procedures provide a consistent and documented methodology for allocating payroll costs and will help ensure payroll expenditures charged to federal awards are adequately supported, accurately calculated, and in compliance with applicable grant requirements. Anticipated Completion Date: Implemented as of January 2026. Name of Contact Person Responsible: Shelley Riser, President and Chief Executive Officer (717) 761-6443
1. Enhanced Training: EVMC will conduct mandatory training for all billing and front-desk staff focusing on accurate annual income calculations, verifying income documentation, and ensuring proper alignment with the active sliding fee discount schedule. Additional focused training will be conducted ...
1. Enhanced Training: EVMC will conduct mandatory training for all billing and front-desk staff focusing on accurate annual income calculations, verifying income documentation, and ensuring proper alignment with the active sliding fee discount schedule. Additional focused training will be conducted whenever a new or updated sliding fee scale is implemented. 2. Monitoring & Quality Audits: EVMC management will establish a formal monthly monitoring and sampling process. The Administrative Assistant and Clinical Manager will audit a representative sample of sliding fee applications and patient billing records. Sampling frequency and sample sizes will be increased immediately following any updates or transitions to new sliding fee schedules to ensure early detection of calculation errors. 3. Individual Accountability & Feedback: Results of monthly audits will be reviewed to identify specific error trends or individual training needs, and corrective retraining will be documented and tracked for continuous improvement.
Student Financial Assistance Cluster– Assistance Listing Nos. 84.268 Recommendation: We recommend Augsburg University implement controls to ensure that disbursement dates reported to COD are aligned with the actual date funds are credited to the student’s account. This could include system controls ...
Student Financial Assistance Cluster– Assistance Listing Nos. 84.268 Recommendation: We recommend Augsburg University implement controls to ensure that disbursement dates reported to COD are aligned with the actual date funds are credited to the student’s account. This could include system controls that delay COD reporting until disbursements are fully processed or periodic reconciliations between COD records and the student ledger to identify and correct discrepancies in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Financial Services will conduct bi-weekly reconciliations between COD records and the student ledger to identify and correct any discrepancies. Name(s) of the contact person(s) responsible for corrective action: Catherine Maun Planned completion date for corrective action plan: May 31, 2027
All staff responsible for registration and income verification in all service lines, programs, and sites received training on income eligibility assessment, documentation, and application in October of 2025. Chart Auditing and Staff Coaching and Corrective Action: ▪ Annual competency assessments for...
All staff responsible for registration and income verification in all service lines, programs, and sites received training on income eligibility assessment, documentation, and application in October of 2025. Chart Auditing and Staff Coaching and Corrective Action: ▪ Annual competency assessments for all registration staff in all service lines, programs, and sites will be part of clinical compliance training between January 1 and February 28, 2027. Competency assessment includes eligibility assessment, documentation, and application. Failure to complete the assessment in the assigned time or failure to complete the assessment successfully will result in letter of expectation with 14 days to demonstrate improvement, followed by formal disciplinary action in the form of a verbal reprimand and 14 business days to remediate before a written reprimand is issued. Completion date for action: 03/31/2027 ▪ Conducting random audits of 2 percent of patients with a visit in a calendar month across all service lines and programs, or a minimum of 90 charts with a standard audit tool that provides scoring to prompt coaching and additional training for staff who fail to meet a 90% benchmark. Completion date for action: On-going. Will have full 2% compliance by 10/31/2026 ▪ Develop automated audit tool that provides real-time feedback on all patient registration records for consistency and accuracy of SFDS screening and documentation. Completion date for action: 12/31/2026 ▪ Work with OCHIN to allow SFDS and income verification in one service line to flow into accounts for all service lines to mitigate issues stemming from different FPLs depending on service line. Completion date for action: 12/31/2026 Contact person: Angela Hurley, Director of Operations Completion date for action: 03/31/2027
View of Responsible Officials The University agrees with the findings and recommendation. Management reviewed the identified exceptions and determined they resulted from the use of incorrect institutional charges and failure to exclude a scheduled break of five or more consecutive calendar days in c...
View of Responsible Officials The University agrees with the findings and recommendation. Management reviewed the identified exceptions and determined they resulted from the use of incorrect institutional charges and failure to exclude a scheduled break of five or more consecutive calendar days in certain Return of Title IV calculations. The University has implemented enhanced procedures to validate institutional charges, identify and exclude qualifying scheduled breaks, provide additional staff training, and require secondary review of Return of Title IV calculations.
FEDERAL AWARD FINDINGS : 2026-001l. HQS Enforcement Corrective Action Plan: Failed HQS inspections did not consistently receive a subsequent re-inspection, or documentation of the re-inspection could not be located. These procedural issues will be addressed with the appropriate staff members and wil...
FEDERAL AWARD FINDINGS : 2026-001l. HQS Enforcement Corrective Action Plan: Failed HQS inspections did not consistently receive a subsequent re-inspection, or documentation of the re-inspection could not be located. These procedural issues will be addressed with the appropriate staff members and will be reviewed by the HCV Department Head to ensure that failed inspéciions are properly followed up on and documented. Additionally, the Authority has hired an additional inspector to help alleviate the worklo ad. and,reduce the burden that was previously placed on a single inspector. This additional staffing will provide greater capacity to complete required inspections and re-inspections in a timely manner. Person/Department Responsible : HCV Department 423-245-013s
Verification Planned Corrective Action: Mid-America Christian University has updated its verification policies and procedures to ensure proper collection, review, and retention of secondary tax documentation. For students whose Federal Tax Information (FTI) cannot be retrieved via the Direct Data Ex...
Verification Planned Corrective Action: Mid-America Christian University has updated its verification policies and procedures to ensure proper collection, review, and retention of secondary tax documentation. For students whose Federal Tax Information (FTI) cannot be retrieved via the Direct Data Exchange (FA-DDX) or whose data is incomplete/unverified, Financial Aid Counselors are required to obtain and retain official IRS Tax Return Transcripts or signed tax returns prior to finalizing aid eligibility. The Financial Aid staff has received comprehensive training on FA-DDX exception handling and acceptable secondary documentation. To ensure ongoing accuracy, the Financial Aid Director (or designee) will perform a 100% Quality Assurance (QA) secondary review of all completed verification files prior to disbursement during the initial rollout phase, transitioning to a structured random sampling protocol once error rates remain at zero. A formal Quality Control Checklist has been incorporated into the operational workflow. Person Responsible for Corrective Action Plan: Tammy Comalander, Interim Director of Financial Aid Anticipated Date of Completion: 07/01/2026
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: Mid-America Christian University (MACU) has conducted a comprehensive audit of all students who earned zero credits during the 2025–2026 academic year to identify any unrecorded unofficial withdrawals and ensure all n...
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: Mid-America Christian University (MACU) has conducted a comprehensive audit of all students who earned zero credits during the 2025–2026 academic year to identify any unrecorded unofficial withdrawals and ensure all necessary Return of Title IV (R2T4) calculations were performed. For any identified deficiencies, funds were processed and returned immediately. To ensure ongoing compliance, MACU has established a standardized protocol between Academic Affairs, the Registrar, and the Financial Aid Office to accurately track the Last Date of Participation /LDP: 1. Faculty Grade & LDP Mandate: Academic Affairs has updated grading procedures to require faculty to record the LDP directly into the Jenzabar whenever a student receives a failing grade or incomplete due to non-attendance/non-participation. 2. Automated Reporting: A term exception report identifies all students with zero earned credits or unearned grades across term modules, enabling the Financial Aid team to promptly verify LDP via Canvas and process R2T4 calculations within federal deadlines. 3. Timeline Enforcement: The Financial Aid Office will enforce standard operating procedures to ensure unofficial withdrawal determinations are completed within 30 calendar days following the term end, and any required Title IV returns are executed within 45 calendar days of the withdrawal determination date (34 CFR 668.22). Person Responsible for Corrective Action Plan: Bobbie Spurgeon-Harris, Executive Vice-President and Chief of Staff Anticipated Date of Completion: 09/30/2026
2026-001 Reporting – Assistance Listing No. 93.224 Recommendation: We recommend the Organization perform a final review of amounts entered within the UDS report, as compared to the supporting schedules, prior to submission. Additionally, all supporting schedules related to amounts included within th...
2026-001 Reporting – Assistance Listing No. 93.224 Recommendation: We recommend the Organization perform a final review of amounts entered within the UDS report, as compared to the supporting schedules, prior to submission. Additionally, all supporting schedules related to amounts included within the UDS report should be maintained and organized in a manner which allows for easy retrieval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Before submitting the UDS, a review will be done of all supporting documentation to verify that the UDS balances with each support. Name of the contact person responsible for corrective action: Tina Taylor, CFO Planned completion date for corrective action plan: 09/01/2026 If
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 th...
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 through August 26, 2029 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: AACHC implemented revised subrecipient monitoring procedures in October 2025 as part of its corrective action plan to address the prior-year finding. The revised procedures were applied to all active and new subrecipient agreements beginning October 2025. However, because certain subrecipient agreements had already concluded before the new procedures were implemented, AACHC did not retrospectively apply the monitoring process to those closed agreements. As a result, AACHC did not obtain and review financial statement audit or Single Audit reports for three subrecipients whose agreements ended prior to implementation of the revised procedures. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2027 Views of Responsible Officials and Corrective Action Plan: In October 2025, AACHC implemented revised subrecipient monitoring procedures in response to the prior-year audit finding. The exception identified in the current audit relates solely to three subrecipient agreements that had already concluded before the revised procedures were implemented and therefore could not be incorporated into the new monitoring process. Effective October 1, 2025, AACHC implemented enhanced procedures requiring evaluation of Single Audit applicability, collection and review of applicable audit reports, and follow-up on any findings. In addition, AACHC now requires subrecipients to submit audit documentation covering the entire period of performance under the agreement, ensuring that monitoring activities are completed even when a subrecipient agreement ends prior to the completion of the audit cycle. This corrective action addresses the circumstances that gave rise to the finding and provides assurance that all subrecipient agreements are subject to appropriate audit review and follow-up moving forward.
1. The Project Sponsor acknowledges the requirements of the HUD Regulatory Agreement regarding the safeguarding and segregation of tenant security deposits. With the transition of management in these areas, additional review controls were implemented, including monthly programmatic and financial rev...
1. The Project Sponsor acknowledges the requirements of the HUD Regulatory Agreement regarding the safeguarding and segregation of tenant security deposits. With the transition of management in these areas, additional review controls were implemented, including monthly programmatic and financial reviews of security deposit collections, postings, and account balances to ensure proper classification and maintenance of restricted funds. 2. On September 4, 2026, the $50 security deposit was transferred to the appropriate security deposit account, fully correcting the deficiency. Management will continue to perform monthly monitoring procedures to verify that all tenant security deposits are accurately recorded and maintained in compliance with HUD requirements.
Finding 2026-001: Considered a material weakness
Finding 2026-001: Considered a material weakness
Recommendation: It is recommended that the Village implement written policies and procedures over significant internal control areas.
Recommendation: It is recommended that the Village implement written policies and procedures over significant internal control areas.
Action to be taken: We agree with the finding and are in the process of implementing written policies and procedures over significant internal control areas including federal award programs.
Action to be taken: We agree with the finding and are in the process of implementing written policies and procedures over significant internal control areas including federal award programs.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
Enrollment Reporting Finding: The enrollment statuses in the National Student Loan Data System for students who took a Regular Academic Hiatus were incorrect during the time of their hiatus. Corrective Actions Taken or Planned: FNU changed its reported enrollment status for all students on a regular...
Enrollment Reporting Finding: The enrollment statuses in the National Student Loan Data System for students who took a Regular Academic Hiatus were incorrect during the time of their hiatus. Corrective Actions Taken or Planned: FNU changed its reported enrollment status for all students on a regular Academic Hiatus (AH) from “Enrolled” to “Leave of Absence (LOA)” in the National Student Clearinghouse (NSC). Note that both status types indicate an enrolled status per NSC. Also, FNU revised internal procedures to ensure that students on a regular AH were coded properly in the Student Learning Management System with a status that aligned with enrollment reporting requirements for a temporary interruption in study. In September 2025, key personnel at FNU completed comprehensive training with NSC regarding reporting timelines and to set up an automated reporting feed from FNU’s Student Learning Management System. FNU repeated the training again in January 2026 to ensure new staff were educated in the process and provide a consistent understanding of the updated procedures. As a result of these actions, FNU demonstrated improved consistency in reporting and timeliness. In addition to these steps, it was determined during 2026 that students submitting late notice to withdraw require a manual update in NSC. The automated data feed does not retroactively capture changes. Training is underway to ensure the offices of Registration and Financial Aid are aware of the file feed limitation and implement a process to update students with approved exceptions to late withdraw. Estimated Completion Date: August 31, 2026. Responsible Personnel: Jessalyn Cornett, Director of Academic Records & Registrar
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