Corrective Action Plans

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Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: Management should receive proper authorization from HUD prior to making additional deposits into the reserve account. Explanation of disagreement with audit f...
Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: Management should receive proper authorization from HUD prior to making additional deposits into the reserve account. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will discuss the additional deposit with HUD. Name(s) of the contact person(s) responsible for corrective action: Debbie (Congdon) Aeschleman Planned completion date for corrective action plan: In process
Health Center Program – Assistance Listing No. 93.224 & 93.527 Recommendation: CLA recommends that the Organization review its FFR to ensure that the grant drawdowns reconcile to the amount reported as federal share of expenditures and any carryover requests are done promptly. Explanation of disagre...
Health Center Program – Assistance Listing No. 93.224 & 93.527 Recommendation: CLA recommends that the Organization review its FFR to ensure that the grant drawdowns reconcile to the amount reported as federal share of expenditures and any carryover requests are done promptly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Moving forward, we will require one person to prepare the FFR and another person to review prior to submission.. Name(s) of the contact person(s) responsible for corrective action: Ryan Gadia, CFO, and Juan Cardenas, Controller Planned completion date for corrective action plan: June 30, 2025
Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Community Development Block Grants/Entitlement Grants Assistance Listing Number: 14.218 Finding Summary: One of three quarterly PR29 Cash on Hand reports submitted to HUD contained an inaccurate figure for revolving ...
Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Community Development Block Grants/Entitlement Grants Assistance Listing Number: 14.218 Finding Summary: One of three quarterly PR29 Cash on Hand reports submitted to HUD contained an inaccurate figure for revolving funds received on Line 13, due to insufficient internal review and reconciliation. Additionally, the amount on Line 5 on the PR26 Financial Summary Report was unable to be supported. Corrective Action Plan: The City will strengthen internal controls over CDBG reporting by: • Implementing a documented secondary review process for all PR29 and PR26 reports. • Requiring reconciliation of source data to report figures prior to submission. Responsible Individual(s): Melissa Kinzler, Finance Director Tom Hazen, Grant Administrator Anticipated Completion Date: January 2026
As documented in our response to the auditor's comment, we plan to monitor and segregate duties as efficiently as possible
As documented in our response to the auditor's comment, we plan to monitor and segregate duties as efficiently as possible
Finding Number: 2025-001 Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: The College has implemented procedures to verify that academic dates are entered accurately in Banner and confirmed by personnel other than those res...
Finding Number: 2025-001 Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: The College has implemented procedures to verify that academic dates are entered accurately in Banner and confirmed by personnel other than those responsible for calculating and reviewing returns of Title IV funds. This should ensure the related calculations are complete and accurate, and the funds are returned in a timely manner. Contact person responsible for corrective action: David Cummins, Vice President for Administrative Services and College Treasurer Anticipated Completion Date: December 2025
Management Response/Corrective Action Plan: In the rare instances when students are removed from a cohort, RSU 34's documentation through Spring 2025 has typically included emails and letters to and from the student's parents, meeting dates / documentation or attempts to engage students and families...
Management Response/Corrective Action Plan: In the rare instances when students are removed from a cohort, RSU 34's documentation through Spring 2025 has typically included emails and letters to and from the student's parents, meeting dates / documentation or attempts to engage students and families in a meeting, and/or logs of phone calls. This communication typically involves the school administration, school counselors, teachers. RSU 34 works hard to engage students in their studies and engage families in helping students to succeed. While RSU 34 views its previous practices as extremely unlikely to result in the stated risk of erroneously removing students from their cohort, RSU 34 instituted an additional formal letter in Spring of '25 and revised that into an accepted form after soliciting feedback from our auditors. Our Data Specialist has inserted that form into their workflow, ensuring it is completed by school administration when removal from a cohort is requested.
2025-002: Late Return of Title [V Financial Aid - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2025 Condition Found During our Return of Title [V Fund testing, we noted that the College did not calculate or return Title IV ...
2025-002: Late Return of Title [V Financial Aid - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2025 Condition Found During our Return of Title [V Fund testing, we noted that the College did not calculate or return Title IV Student Financial Aid for two out of twenty-five students tested until after 45 days when the ryan student ceased attendance. We consider the untimely calculation and Return of Title TV Student Financial Aid to be an instance of noncompliance relating to the Special Tests and Provisions Compliance Requirement. This is a repeat finding of prior year Finding 2024-001. Corrective Action Plan To strengthen compliance with R2T4 timelines, the Financial Aid Office has implemented enhanced monitoring and workflow procedures. Responsibility for the weekly review and processing of R2T4 calculations has been reassigned to the Coordinator of Student Loans, ensuring consistent oversight and timely completion of required actions. Meetings are held every Wednesday to address any cases requiring follow-up creating a checkpoint to prevent delays. Responsible Person for Corrective Action Plan Coordinator of Student Loans Executive Director of Financial Aid Implementation Date of Corrective Action Plan 10/01/2025
2025-001 Federal Work Study - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our Federal Work Study testing, we selected twenty-five students and noted that one student was paid for hours they did...
2025-001 Federal Work Study - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our Federal Work Study testing, we selected twenty-five students and noted that one student was paid for hours they did not work and was overpaid $420. The College did not review federal work study hours worked against class hours scheduled and timesheets to ensure the student was not working during a scheduled class and that they were paid for the correct number of hours. We consider this condition to be an instance of non-compliance to the Eligibility compliance requirement. Corrective Action Plan The Financial Aid Department is collaborating with Career Services to implement improved oversight and training for Federal Work-Study. This includes required online training for both student employees and their supervisors, which must be completed prior to hiring any student employees within a department. Additionally, a campus-wide Standard Operating Procedure (SOP) has been developed, along with a Quick Guide for Supervisors of Student Employees, to ensure consistent processes and expectations related to scheduling, timesheet review, and compliance. Responsible Person for Corrective Action Plan Program Manager — Student Employment/Veteran Affairs Director of Career Services and Job Placement Implementation Date of Corrective Action Plan 08/22/2025
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls to actively monitor the work order system to ensure appropriate repairs are being completed in a timely manner.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls to actively monitor the work order system to ensure appropriate repairs are being completed in a timely manner.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Reporting views of responsible officials and planned corrective actions The Organization will enhance its controls and procedures to ensure financial reporting is complete, accurate, and timely.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made depos...
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made deposits into the reserve for replacement to make up the shortfall. Management will work with the Bank and HUD to ensure the accuracy of the “true-up” payments made.
Individuals Responsible for Corrective Action Plan: •Collections Coordinator •Director of Student Accounts Condition: Life University transitioned from UAS services to ECSI. In the transition of that service provides, documentation that was to be maintained to remain compliant with the Federal Perki...
Individuals Responsible for Corrective Action Plan: •Collections Coordinator •Director of Student Accounts Condition: Life University transitioned from UAS services to ECSI. In the transition of that service provides, documentation that was to be maintained to remain compliant with the Federal Perkins loan program was lost. The university has attempted on numerous occasions to assign the defaulted loans using alternative documentation to verify the debt. All attempts have been denied. The university has now been in practice with the current corrective action plan to address the deficiencies in documentation and reestablish the validity of the debt. Management’s Corrective Action Plan: Life University has implemented and continues to maintain the following corrective measures to ensure ongoing compliance: 1.Borrower Contact and Notification Life University has initiated and continues to conduct proactive outreach to borrowersrequiring an updated or newly established MPN (Master Promissory Note) or equivalentdocumentation. Communication is conducted through multiple channels, including: •Phone •Email 2.Clear Documentation Instructions The University will continue to issue formal notices to affected borrowers outlining therequirement for a new MPN or equivalent documentation. Each notice includes step-by-stepinstructions for completion, a clear explanation of the purpose and importance of the MPN,and information regarding its impact on the borrower’s outstanding loan balance. 3.Reassignment of Collection Rights Upon borrower completion of the required documentation, Life University has coordinatedwith ECSI to reassign the University’s right to collect on any remaining balances. This processcontinues to be applied as additional borrowers complete their documentation. 4.Documentation Review and Verification The University has established and continues to follow a review process to verify that eachnew MPN is complete, accurate, and properly executed. This ensures that borrower consentis valid and that all collection rights are appropriately reassigned. 5.Financial Record Updates Life University has updated and continues to maintain accurate financial records reflectingthe new MPNs and reassigned collection rights. Outstanding amounts, repayment schedules,and related data are verified and recorded to ensure consistency with federal andinstitutional requirements. 6.Ongoing Communication and Monitoring The University continues to monitor borrower compliance and maintain communicationthroughout the process. Regular follow-ups and reminders are sent as needed to ensuretimely completion and documentation integrity. At the conclusion of a 12 month outreach,students who have not verified their debt to come within compliance will be written off. Anticipated Completion Date: ongoing
THE ORGANIZATION WILL CREATE A FILE THAT WILL CONTAIN ALL FILES THAT REQUIRE ADDITIONAL DOCUMENTATION OR COMPLETION. CHILDCARE OPERATIONS WILL COMMUNICATE TO THE SITE DIRECTORS THAT CONSUMER FILES ARE MISSING, AND THIS WILL BE COMMUNICATED DIRECTLY TO THE FAMILIES. IF NEEDED THE FAMILY FOCUSED CASE ...
THE ORGANIZATION WILL CREATE A FILE THAT WILL CONTAIN ALL FILES THAT REQUIRE ADDITIONAL DOCUMENTATION OR COMPLETION. CHILDCARE OPERATIONS WILL COMMUNICATE TO THE SITE DIRECTORS THAT CONSUMER FILES ARE MISSING, AND THIS WILL BE COMMUNICATED DIRECTLY TO THE FAMILIES. IF NEEDED THE FAMILY FOCUSED CASE MANAGER WILL ARRANGE TO GATHER THE REQUIRED DOCUMENTS AT THE HOMES OF THESE FAMILIES. A MONTHLY REVIEW OF FILES WILL OCCUR AND FILES THAT CONTINUE TO HAVE MISSING INFORMATION WILL INVOLVE THE REQUEST FOR IN-PERSON MEETINGS WITH THE FAMILIES. IF MISSING DOCUMENTATION CONTINUES TO BE INCOMPLETE FOR FIVE BUSINESS DAYS, A REQUEST FOR DISENROLLMENT OF THE CHILD WILL OCCUR.
Underfunding of Replacement Reserve Significant Deficiency in Internal Control over Compliance and an Immaterial Instance of Noncompliance Finding Summary: During testing, it was identified that the Organization did not increase the monthly deposit to the replacement reserve in a timely manner, whic...
Underfunding of Replacement Reserve Significant Deficiency in Internal Control over Compliance and an Immaterial Instance of Noncompliance Finding Summary: During testing, it was identified that the Organization did not increase the monthly deposit to the replacement reserve in a timely manner, which resulted in an underfunded account. Responsible Individuals: Management Corrective Action Plan: Management will implement a process to ensure that the required monthly deposits be updated timely. Anticipated Completion Date: September 30, 2026
2025-002 Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Centennial Square should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of their annual financ...
2025-002 Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Centennial Square should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of their annual financial statements can be implemented to provide reasonable assurance that the financial statements are free of material misstatement and prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will evaluate controls, processes, and job duties during the upcoming year in order to ensure the control structure is sufficient to detect material misstatement to the consolidated financial statements. Name(s) of the contact person(s) responsible for corrective action: Tammy Gjerde, Finance Director
2025-001 Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Centennial Square should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of annual financial st...
2025-001 Section 202 Capital Advance – Assistance Listing No. 14.157 Recommendation: Centennial Square should evaluate their financial reporting processes and controls, including the expertise of its internal staff, to determine whether additional controls over the preparation of annual financial statements can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will continue to rely on CliftonLarsonAllen to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance. Name(s) of the contact person(s) responsible for corrective action: Tammy Gjerde, Finance Director
Incorrect Pell Calculations Planned Corrective Action: The Office of Financial Aid will obtain enrollment reports for each term and session to ensure that Pell Grant eligibility is accurately determined and awarded to students based on their enrollment intensity. To address the system limitations id...
Incorrect Pell Calculations Planned Corrective Action: The Office of Financial Aid will obtain enrollment reports for each term and session to ensure that Pell Grant eligibility is accurately determined and awarded to students based on their enrollment intensity. To address the system limitations identified, the University has acquired a new Software-as-a-Service (SaaS) financial aid management system. Person Responsible for Corrective Action Plan: Executive Director of Financial Aid, Robert Hamilton, and Assistant Director of Compliance & Reporting, Brooke Tyler Anticipated Date of Completion: June 30, 2026
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The Executive Director of Financial Aid and the Assistant Director of Compliance & Reporting will provide regular in-house R2T4 training specific to WBU for all financial aid staff. All financial aid staff responsible...
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The Executive Director of Financial Aid and the Assistant Director of Compliance & Reporting will provide regular in-house R2T4 training specific to WBU for all financial aid staff. All financial aid staff responsible for R2T4 will be required to complete pertinent training provided by FSA and purchased through NASFAA. In addition, financial aid staff responsible for R2T4 have established procedures to ensure the accurate and timely Return of Title IV Funds. To address the system limitations identified, the University has acquired a new Software-as-a-Service (SaaS) financial aid management system. Person Responsible for Corrective Action Plan: Executive Director of Financial Aid, Robert Hamilton, and Assistant Director of Compliance & Reporting, Brooke Tyler, and Assistant Director of Financial Aid, Alyssa Shealor Anticipated Date of Completion: June 30, 2026
Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No. 21.027 U.S. Department of Treasury Missouri Primary Care Association Criteria or specific requirement – Reporting (2 CFR 200.329) Condition – The Organization’s internal controls over compliance were not able to ensure progress...
Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No. 21.027 U.S. Department of Treasury Missouri Primary Care Association Criteria or specific requirement – Reporting (2 CFR 200.329) Condition – The Organization’s internal controls over compliance were not able to ensure progress reporting required to be submitted to the pass-through entity was completed timely. Cause – The Organization’s internal controls over compliance did not ensure all grant reporting requirements were completed timely. Effect or potential effect – The Organization did not submit the required quarterly and annual performance reports in a timely manner. Questioned costs – None Context – The Organization is required to submit quarterly status reports and an annual performance report to the pass-through entity in a timely manner. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should consider implementing a grant reporting calendar for all grants with reporting requirements. Views of responsible officials and planned corrective actions – In order for this finding not to occur in the future, the Chief Financial Officer will • Create a Grant calendar to track report due dates • Hold quarterly meetings with managers to ensure we have all reports submitted timely in the future Contact person responsible for corrective action – Toby Barnett, Chief Financial Officer Anticipated completion date – December 2025
Management's Response: We concur. Views of Responsible Officials and Corrective Action Plan Response: The two students identified were underpaid due to locks on their financial aid units for either late-start courses or being on an approved SAP appeal plan. Once locks were removed, PowerFAIDS should...
Management's Response: We concur. Views of Responsible Officials and Corrective Action Plan Response: The two students identified were underpaid due to locks on their financial aid units for either late-start courses or being on an approved SAP appeal plan. Once locks were removed, PowerFAIDS should have recalculated their aid to reflect their current units, however that did not happen. As a result, the Pell Grant was under-awarded. The students have now been disbursed with their full Pell eligibility. Corrective Action Plan: The transition from a legacy SIS and PowerFAIDS to a single ERP will consolidate financial aid and enrollment data into a single system, eliminating reliance on manual adjustments and reducing the risk of data discrepancies between two systems. Banner allows for automated and real-time recalculations for enrollment changes such as late start courses, reducing the risk of Pell under or over-awarding. Financial aid staff will receive updated training and guidance on the importance of verifying Pell recalculations when manual locks on student financial aid records are needed, for instance in the case of a student on an approved SAP appeal plan.
The following is the Recruitment and Admissions Corrective Action Plan for the single Audit Finding for FY25. Criteria or Specific Requirement: Special Tests and Provisions – NSLDS Reporting, 34 CFR Sections 690.83 (b)(2) and 685.309. Finding Summary: Student enrollment and program information was n...
The following is the Recruitment and Admissions Corrective Action Plan for the single Audit Finding for FY25. Criteria or Specific Requirement: Special Tests and Provisions – NSLDS Reporting, 34 CFR Sections 690.83 (b)(2) and 685.309. Finding Summary: Student enrollment and program information was not communicated to the National Student Loan Data System (NSLDS) timely or accurately. Officials Responsible for Ensuring Corrective Action: Shanna Pope, Registrar Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding and will implement enhanced procedures to ensure internal controls support the timely and accurate reporting of student status, program, and completion information to the National Student Loan Data System (NSLDS). For each National Student Clearinghouse (NSC) file submitted, students with status, program, or completion changes will be systematically identified and flagged for review. Registrar staff will conduct a targeted, sample-based review of these flagged records directly within NSLDS to verify that data transmitted from NSC was received, processed, and reflected accurately. All policies and procedures governing enrollment reporting and the processing of student status, program, and completion changes will be reviewed, revised as necessary, and formally implemented no later than April 1, 2026, to align with this corrective action.
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