Corrective Action Plans

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FINDING 2025-002 Finding Subject: Contact Person Responsible for Corrective Action: Tracey Haas, Business Manager Contact Phone Number and Email Address: 219-873-2000 x 8346 thaas@mcas.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We wil...
FINDING 2025-002 Finding Subject: Contact Person Responsible for Corrective Action: Tracey Haas, Business Manager Contact Phone Number and Email Address: 219-873-2000 x 8346 thaas@mcas.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will implement a system of internal controls to ensure that the Form 9 and all underlying expenditures are properly documented. Anticipated Completion Date: We anticipate that this correction will be in place by July 2027
Corrective Actions 1. Immediately cease noncompliant payment practices • Stop all direct payments or reimbursements to private schools • Communicate the change to all stakeholders 2. Establish compliant fiscal procedures • Ensure the district (LEA) retains control of Title I funds at all times • Pay...
Corrective Actions 1. Immediately cease noncompliant payment practices • Stop all direct payments or reimbursements to private schools • Communicate the change to all stakeholders 2. Establish compliant fiscal procedures • Ensure the district (LEA) retains control of Title I funds at all times • Payments must be made: o To third-party vendors, or o For district-managed services (staff, materials, contracts) • Update written fiscal procedures to explicitly prohibit: o Reimbursement-based arrangements with private schools o Direct cash transfers to private schools • Require pre-approval for all Title I expenditures related to equitable services 3. Implement a vendor-based service model • Contract with approved vendors to provide services to private school students 4. Strengthen review and approval processes • Require multi-level approval (program+ finance) before payments • Cross-check expenditures against: o Approved equitable services plan o Student eligibility and services provided 7. Provide targeted fiscal training • Train finance and program staff on: o Control of funds requirements o Allowable vs. unallowable costs under Title I
CORRECTIVE ACTION PLAN FOR FINDING 2025-001 Identifying Number: 2025-001 Finding: For the Federal Award Identification Number: 84.215, contract number (S215J230147), the reporting requirement for FFAFTA reporting, due August 31, 2024 was not met. Required reporting was submitted on January 28, 2026,...
CORRECTIVE ACTION PLAN FOR FINDING 2025-001 Identifying Number: 2025-001 Finding: For the Federal Award Identification Number: 84.215, contract number (S215J230147), the reporting requirement for FFAFTA reporting, due August 31, 2024 was not met. Required reporting was submitted on January 28, 2026, which was after the submission due date. Corrective Action Taken: Metropolitan Family Services will implement a process to ensure new contracts are reviewed so we are adhering to reporting requirements. The Assistant Budget Directors have been notified to review the reporting requirements more closely. The initial review of the reporting requirements will be conducted by the Assistant Budget Directors, and a final review will be by the Budget Director. Responsible Individuals: This will be completed by the following Assistant Budget Directors: Casey Maher Leticia Reyes Jeff Sklenar Emilia Vargas Gaz Meni Ramiro Chavez Reviews will be performed by the Budget Director (Don Pyznarski). Anticipated Completion Date: The anticipated completion date is June 1, 2026.
Recommendation We recommend the District implement documented daily edit checks reconciling meal counts to attendance records and maintain records of this review. For food inventory, the District should establish a formal inventory system, including perpetual inventory records, monthly physical coun...
Recommendation We recommend the District implement documented daily edit checks reconciling meal counts to attendance records and maintain records of this review. For food inventory, the District should establish a formal inventory system, including perpetual inventory records, monthly physical counts, and supervisory review. Staff involved in Child Nutrition operations should receive training on USDA and federal compliance requirements Management Response Corrective Action The Food Service Director will implement the federally required daily edit check process. This will include comparing daily meal counts against the attendance and enrollment figures to ensure that claims do not exceed the number of students present. Any discrepancies identified during this process will be investigated and documented prior to submission of the monthly claim. The District will also change the tracking of meals served by using an official meal tracking device or by having students use their badge/ID cards to get a more accurate meal count each day. The District has a formal inventory process for all food service supplies including canned goods, dry goods, and freezer items. This system tracks items from receipt through consumption. The District conducts monthly physical inventory counts of all food service assets. These counts are reconciled and any significant variances are reviewed by the Food Service Director and reported to the Business Manager. The District will ensure that all nutrition staff is trained on these procedures as well. Due Date of Completion: June 30, 2026 Responsible Party Business Manager, Food Service Director
Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting ...
Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting the financial statements, related footnote disclosures and SEFA in accordance with the accounting principles generally accepted in the United States of America (U.S. GAAP).
Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than...
Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than the competence required to prepare the financial statements, related footnote disclosures and SEFA in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP).
We will continue to monitor our procedures and implement additional controls where possible.
We will continue to monitor our procedures and implement additional controls where possible.
Auditors Recommendation: We recommend that management implement and enforce procedures to ensure Replacement Reserve deposits are made in the required amounts and at the required frequency, including periodic review by management to ensure ongoing compliance with HUD requirements. Action Taken: Goin...
Auditors Recommendation: We recommend that management implement and enforce procedures to ensure Replacement Reserve deposits are made in the required amounts and at the required frequency, including periodic review by management to ensure ongoing compliance with HUD requirements. Action Taken: Going forward, we will create a procedure for the Finance team to make the required deposits to the HUD reserve accounts In the future, noting, dates, and amounts to make. They will be added to our month end reconciliations. We have caught up, and made necessary deposits to date, and are current.
Auditors Recommendation: We recommend that management implement and enforce procedures requiring documented HUD approval prior to any use of replacement reserve funds, including review and approval by appropriate management personnel, to ensure compliance with HUD requirements. Action Taken: We were...
Auditors Recommendation: We recommend that management implement and enforce procedures requiring documented HUD approval prior to any use of replacement reserve funds, including review and approval by appropriate management personnel, to ensure compliance with HUD requirements. Action Taken: We were not aware that use of these funds required HUD approval. We are creating a policy to prevent any use of the HUD Reserve Account funds, without prior approval from HUD. We have subsequently returned all funds that were borrowed with prior HUD authorization, and will not access them in the future, without proper approval from HUD.
Finding Number: 2025-002; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client files contain documentation ensuring complia...
Finding Number: 2025-002; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client files contain documentation ensuring compliance with Rent Reasonableness requirements. Anticipated Completion Date: 6/30/26; Responsible Contact Person: Kristen Runion, HCV Supervisor
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of mont...
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of monthly audits performed by service line leaders will be reported to senior leadership. An internal audit will be done by the compliance team and presented to leadership on a quarterly basis. All appropriate admitting staff will go through training to reinforce our slide process and review procedures for all FQHC services.
Finding 1205432 (2025-002)
Material Weakness 2025
Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Secti...
Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Refresher training sessions will be fully completed for all Medicaid staff by the end of January 2026. Documentation standards and quality review processes are already in effect, with ongoing monitoring. Angel Carpenter and Goldie Davis - Medicaid Supervisors All Medicaid caseworkers will complete targeted refresher training on key eligibility and budgeting rules, including the use of online verification systems, accurate income and deduction calculations, household composition, recertification processes, and proper case documentation standards. Training will be delivered through a combination of state Learning Gateway courses, webinars, and internal sessions, with knowledge checks to confirm understanding. Staff will be reminded that “if it’s not documented, it didn’t happen.” Standardized documentation templates have been created and are now required for all cases to ensure thorough, clear, and consistent case notes. Second-party case reviews will continue and be expanded as needed to monitor ongoing accuracy. Case errors and lessons learned will be regular agenda items at monthly staff meetings, with emphasis on double-checking determinations before authorizing or releasing cases in NC FAST. Dedicated weekly time will be protected for staff to work pending verifications and system reports, with supervisory review. Section II - Financial Statement Findings 8/14/2025 Nikki Stanton, Finance Director The Nash County Finance Director was appointed effective April 14, 2025. Since that time, Finance has undertaken the following measures to strengthen operations and internal controls: • Reclassified job duties to better align responsibilities with organizational needs and improve efficiency. • Implemented additional internal controls to enhance the reliability and accuracy of financial processes. • Recruited and onboarded a dedicated Accountant to support the Accounting Manager. These changes have enabled the Accounting Manager to concentrate on performing timely reconciliations and preparing accurate journal entries, thereby improving the overall timeliness and quality of financial reporting. For the Year Ended June 30, 2025 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 188
Condition: During our testing of controls over payroll, we identified three instances of payroll summary reports lacking an indication of review and approval. Criteria: The Uniform Guidance 2 CFR 200.303 requires auditees to establish and maintain effective internal control over federal awards that ...
Condition: During our testing of controls over payroll, we identified three instances of payroll summary reports lacking an indication of review and approval. Criteria: The Uniform Guidance 2 CFR 200.303 requires auditees to establish and maintain effective internal control over federal awards that provides reasonable assurance that the awards are being managed in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The Organization should have a system of internal control in place to provide reasonable assurance that payroll summary reports are accurate and are being reviewed. Repeat of Prior Year Finding: No. Auditor’s Recommendation: We recommend that payroll summary reports be reviewed and approved prior to completing the payroll process. If the Executive Director is unavailable, another staff member should review and approve the reports so the payroll process can be completed. Management’s Response: Payroll reports will be reviewed and approved by the Executive Director. If the Executive Director is unavailable, another staff member will review and approve the reports. The Executive Director has reviewed and approved all payroll reports to date. Completion Date: March 17, 2026
Develop and formally adopt a written procurement policy compliant with 2 CFR 200.317 - 200.327 Train all staff involved in procurement to ensure consistent understanding and proper implementation Perform periodic reviews and updates of the procurement policy to maintain compliance with evolving fede...
Develop and formally adopt a written procurement policy compliant with 2 CFR 200.317 - 200.327 Train all staff involved in procurement to ensure consistent understanding and proper implementation Perform periodic reviews and updates of the procurement policy to maintain compliance with evolving federal requirements.
Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct ...
Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct Loan, and Federal Family Education Loan (“FFEL”) programs. The University concurs with the finding and recognizes the importance of accurate and timely reporting to the National Student Loan Data System (“NSLDS”) in accordance with federal requirements (OMB No. 1845-0035). The University is committed to strengthening internal controls, enhancing operational procedures, and ensuring full compliance with all enrollment reporting requirements. II. Criteria Institutions participating in federal student aid programs are required to: • Report accurate enrollment information through NSLDS, including enrollment status and program-level data elements. • Ensure that all significant data elements—including enrollment status, program begin date, and enrollment effective date—are accurate as of the reporting date. • Submit enrollment reporting updates at least every 60 days (bi-monthly). • Maintain adequate internal controls to ensure data integrity and compliance with federal regulations. III. Condition The audit identified errors in enrollment reporting for a sample of 25 students, including: • 2 instances of incorrect program enrollment effective date reporting These errors were attributed to administrative oversight and insufficient internal controls governing enrollment reporting processes. IV. Cause Analysis The University has identified the following contributing factors: • Insufficient internal controls and review mechanisms over enrollment status updates • Limited system automation and alert capabilities for tracking status changes • Inadequate staffing resources to manage reporting timelines and data verification • Lack of formalized cross-functional coordination between the Office of the Registrar and reporting entities • Absence of an independent monitoring function to ensure compliance consistency V. Corrective Actions and Implementation Plan The University will implement the following corrective actions to address the identified deficiencies: 1. Establishment of Internal Audit Function • The University will establish a formal Internal Audit function by the start of the next academic year. • This function will have broad authority to oversee compliance, enforce corrective actions, and evaluate internal controls across all relevant departments. • Internal Audit will lead ongoing reviews of enrollment reporting processes and ensure accountability. 2. Process Review and Cross-Functional Collaboration • Internal Audit will coordinate a comprehensive review of enrollment reporting processes involving the Office of the Registrar and the National Student Loan Clearinghouse. • This review will include a structured assessment of strengths, weaknesses, opportunities, and risks (SWOT analysis). • Standard operating procedures (SOPs) will be updated and formally documented. 3. Staffing and Resource Enhancements • The University will enhance staffing within the Office of the Registrar to support enrollment reporting functions. • Additional technological tools and system capabilities will be implemented to provide automated alerts, status tracking, and exception reporting. 4. Implementation of Monitoring and Control Systems • A robust monitoring system will be deployed to: o Track student enrollment status changes in real time o Generate alerts for discrepancies or missing data o Ensure timely submission of required updates to NSLDS • Data validation checkpoints will be integrated prior to submission to ensure accuracy. 5. Strengthening Reporting Protocols • Interim control measures will include the submission of transfer student status reports on a semester basis until full remediation is achieved. • All enrollment updates will undergo a secondary review and certification prior to submission. • A compliance calendar will be implemented to ensure adherence to the 60-day reporting requirement. 6. Training and Accountability Measures • Mandatory training sessions will be conducted for all personnel involved in enrollment reporting. • Training will focus on federal requirements, data accuracy standards, and system utilization. • Performance expectations and accountability metrics will be clearly defined and monitored. VI. Timeline for Implementation • Immediate (0–90 Days): o Initiate staffing enhancements o Implement interim review and validation procedures o Conduct training sessions • Short-Term (90–120 Days): o Deploy monitoring and alert systems o Formalize SOPs and compliance calendar o Begin enhanced reporting protocols • Long-Term (By Start of Next Academic Year): o Fully establish Internal Audit function o Complete comprehensive process review and continuous monitoring framework VII. Monitoring and Ongoing Compliance The Internal Audit function will conduct periodic reviews and report findings for executive leadership. Continuous monitoring will ensure that corrective actions remain effective and that compliance with federal regulations is sustained. VIII. Conclusion Through the implementation of these corrective measures, the University will address the deficiencies identified in Finding 2025-001 and significantly strengthen its internal control environment. These actions will ensure accurate and timely enrollment reporting, uphold the integrity of federal student aid programs, and reinforce the University’s commitment to regulatory compliance and operational excellence. Anticipated Completion Date: September 1, 2026
Finding: The company did not implement the HUD approved rent adjustments for October 2024 in a timely fashion. Corrective Actions Taken: Management subsequently made the retroactive adjustments to HUD which have been approved by and paid to HUD. In addition, management has implemented a formal revie...
Finding: The company did not implement the HUD approved rent adjustments for October 2024 in a timely fashion. Corrective Actions Taken: Management subsequently made the retroactive adjustments to HUD which have been approved by and paid to HUD. In addition, management has implemented a formal review and corss-verification process to ensure that rent adjustments are completed accurately and in a timely manner.
HeadStart Assistance Listing No. 93.600 Recommendation: We recommend that DCHS review procedures and internal controls to ensure that the required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Documentation o...
HeadStart Assistance Listing No. 93.600 Recommendation: We recommend that DCHS review procedures and internal controls to ensure that the required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Documentation of supporting compliance should be readily available for review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The reporting has been completed. New employees will be trained in the procedures and internal controls to ensure that the required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Documentation will be available for review during the audit period. Name(s) of the contact person(s) responsible for corrective action: Noah Abraham, DCHS Operations Director. Planned completion date for corrective action plan: Complete
2025-003 Material Weakness Internal Control – Special Tests / Prevailing wages C. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for obtaining certified payrolls as needed in conjunction with construction projects. D. Actions Taken or Planned: Management will requ...
2025-003 Material Weakness Internal Control – Special Tests / Prevailing wages C. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for obtaining certified payrolls as needed in conjunction with construction projects. D. Actions Taken or Planned: Management will request certified payrolls for any future construction contracts as required by federal regulation. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
2025-002 Material Weakness Internal Control / Noncompliance – Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current...
2025-002 Material Weakness Internal Control / Noncompliance – Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information captured and reported in accordance with the required timelines by implementing additional oversight. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
2025-003 Program Name: Environmental Justice Thriving Communities Grantmaking Program; Assistance Listing Number: 64.615 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements mad...
2025-003 Program Name: Environmental Justice Thriving Communities Grantmaking Program; Assistance Listing Number: 64.615 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements made with federal funds. Disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented additional controls to ensure that each program has documented procedures to submit required reports timely and accurately. The untimely filing of reports in fiscal year 2025 resulted from a change in personnel. During fiscal year 2026, management identified all applicable reporting requirements and assigned responsibility to appropriate personnel. Additional procedures were implemented to ensure reports are reviewed and submitted in accordance with required deadlines. Name of the contact person responsible for corrective action: Beth Doreian, CFO Planned completion date for corrective action plan: March 1, 2026
2025-002 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements ma...
2025-002 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements made with federal funds. Disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented additional controls to ensure that each program has documented procedures to submit required reports timely and accurately. The untimely filing of reports in fiscal year 2025 resulted from a change in personnel. During fiscal year 2026, management identified all applicable reporting requirements and assigned responsibility to appropriate personnel. Additional procedures were implemented to ensure reports are reviewed and submitted in accordance with required deadlines. Name of the contact person responsible for corrective action: Beth Doreian, CFO Planned completion date for corrective action plan: March 1, 2026
2025-001 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Procurement Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements m...
2025-001 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Procurement Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements made with federal funds. Disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented additional procedures to ensure that required procurement documentation is appropriately retained for each vendor in accordance with Uniform Guidance requirements. These procedures were implemented and management considers the matter to be fully remediated during fiscal year 2026. Name of the contact person responsible for corrective action: Beth Doreian, CFO Planned completion date for corrective action plan: March 1, 2026
U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization review controls in place to ensure expenses are approved and maintain evidence of approval. Explanation of disagreemen...
U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization review controls in place to ensure expenses are approved and maintain evidence of approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New Management has adopted a new A/P process for invoice approvals. Approved invoices are required for expenses to be paid. All autopay features on utility bills has been removed. Name(s) of the contact person(s) responsible for corrective action: Kate Mombourquette Planned completion date for corrective action plan: Completed 12/31/2025
U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design and implement controls to ensure that time and effort related to federal programs is appropriately documented a...
U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design and implement controls to ensure that time and effort related to federal programs is appropriately documented and retained in accordance with Uniform Guidance requirements, regardless of contract type. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New Management is continuing advocacy to recover missing documentation from previous payroll provider. New payroll provider maintains all records and archives. For those employees who work on federal grants, attestations of time spent on programs are being produced. Name(s) of the contact person(s) responsible for corrective action: Kate Mombourquette Planned completion date for corrective action plan: Completed 12/31/2025
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WAU agrees with the recommendation to update our formal process to identify and maintain an inventory of data, devices, and systems that support or process customer f...
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WAU agrees with the recommendation to update our formal process to identify and maintain an inventory of data, devices, and systems that support or process customer financial aid information. While we currently use the Spiceworks Inventory System to track hardware and software assets and Google Workspace to manage user cloud access and data storage, we acknowledge that a formal, documented inventory process covering all required categories has not yet been fully established. The IT Director has been assigned to develop and document this process within 30 days. We acknowledge this finding and the associated risk arising from the absence of an independent risk assessment. As of March 25, 2026, the University has engaged TeamLogic Cybersecurity to strengthen our managerial, technical, and operational controls and to (1) develop and document a formal, GLBA aligned risk assessment process; (2) conduct annual independent, comprehensive risk assessment of our information systems and data environment; and (3) provide written findings and recommendations. Based on these results, we will implement appropriate safeguards, and institutionalize an annual risk assessment cycle to ensure that risks are consistently identified, assessed, mitigated, and monitored in accordance with GLBA requirements. Name(s) of the contact person(s) responsible for corrective action: Rosalee Pedapudi, IT Director, Information Technology Services Planned completion date for corrective action plan: April 26, 2026
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