Corrective Action Plans

Finding 1176687 (2025-002)

Material Weakness 2025

Minooka Community High School District #111

IL

Reporting Internal Control / Segregation of Duties

The Assistant Superintendent, along with staff, will review the capital asset schedules as part of the audit preparation process to prepare fully adjusted financial statements prior to audit fieldwork.

View Audit 390566

Finding 1176686 (2025-001)

Material Weakness 2025

Minooka Community High School District #111

IL

Reporting Internal Control / Segregation of Duties

The District implemented a new capital asset appraisal in order to have accurate historical records of all assets owned by the District. These schedules will be updated on an annual basis to reflect accurate reporting requirements.

View Audit 390566

Finding 1176676 (2025-003)

Material Weakness 2025

Community Mental Health Affilates, Inc.

CT

Questioned Costs Cash Management Reporting § 200.516

Corrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Corre...

Corrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: For FY26 procedures have been put in place to maintain a schedule of reporting due dates that are reviewed monthly to ensure timely submissions.

View Audit 390542

Finding 1176675 (2025-002)

Material Weakness 2025

Community Mental Health Affilates, Inc.

CT

Questioned Costs Cash Management Reporting § 200.516

orrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Correc...

orrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: For FY26 procedures have been put in place to maintain a schedule of reporting due dates that are reviewed monthly to ensure timely submissions.

View Audit 390542

Finding 1176647 (2025-002)

Material Weakness 2025

Vanderbilt University Medical Center

TN

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Federal Program: Department of Homeland Security Assistance Listing: 97.036 Federal Agency: COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Entity: State of Tennessee Grant Award Number: All FEMA Projects (Projects 435263,550461, 684580) Award Per...

Federal Program: Department of Homeland Security Assistance Listing: 97.036 Federal Agency: COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Entity: State of Tennessee Grant Award Number: All FEMA Projects (Projects 435263,550461, 684580) Award Period: Project 435263: 1/1/2020-7/31/2021 Project 550461: 1/1/2020-7/31/2021 Project 684580: 8/1/2020-6/30/2022 Management understands that additional audit evidence must be retained at a detailed enough level to allow the auditor to meet their reperformance standard. All expenses claimed were eligible and were reviewed by management prior to the submission. The control issue identified is due to the lack of evidence to support approval. Should management have a future FEMA claim we will retain additional audit evidence to enable auditor reperformance of the controls regarding approval of expenditures. Paula Yarbrough, VUMC Director – Grants and Contracts will be responsible for the implementation by fiscal year-end 2026.

View Audit 390522

Finding 1176645 (2025-011)

Material Weakness 2025

Second Judicial District Court

NM

Questioned Costs Subrecipient Monitoring Reporting

The agency concurs with this finding as the documents provided by the agency showed that some contracts that were modified and met the required threshold for FFATA reporting was not done when the modifications were approved. FFATA reporting has been done by the agency but a breakdown in the reportin...

The agency concurs with this finding as the documents provided by the agency showed that some contracts that were modified and met the required threshold for FFATA reporting was not done when the modifications were approved. FFATA reporting has been done by the agency but a breakdown in the reporting process by the agency did not include reporting contracts that has modification. The agency is revising internal policies and procedures to ensure all staff responsible for FFATA reporting understand that all contracts, including contracts that have modifications that increase funding up to the threshold of FFATA reporting, must be included in the FFATA reporting. Continuous training will be done for all financial staff responsible for FFATA training.

View Audit 390502

Finding 1176642 (2025-009)

Material Weakness 2025

Second Judicial District Court

NM

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.430

The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added...

The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added communication levels to ensure that more than one person received communication between ASD and agency divisions. The ASD division has implemented better communication lines between the ASD division and the agency divisions which will resolve this issue. With more than one person receiving the information and additional training on ensuring that all reconciling items are addressed timely the agency general ledger will remain clean and in balance with allowable expended posted to the correct Chatfield’s.

View Audit 390502

Finding 1176638 (2025-006)

Material Weakness 2025

Children's Home of Kingston

NY

Reporting Internal Control / Segregation of Duties

The Agency's management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency under the oversight of newly hired Financial Controller Kimberly Houghton-Bryan will develop monthly and quarterly...

The Agency's management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency under the oversight of newly hired Financial Controller Kimberly Houghton-Bryan will develop monthly and quarterly closing procedures to aid in the timely closing and filing of reports required by Assistance Listing No. 93.676. Financial Controller, Kimberly Houghton-Bryan, is to implement the checklist by March 31, 2026, to ensure that regulatory reporting is prepared in timely manner.

View Audit 390500

Finding 1176630 (2025-001)

Material Weakness 2025

City of Camarillo

CA

Questioned Costs Allowable Costs / Cost Principles Reporting

The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required t...

The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required timeframes going forward.

View Audit 390483

Finding 1176625 (2025-008)

Material Weakness 2025

Oregon Association of Relief Nurseries

OR

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.305

Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring remittance of federal funds directly to subrecipients, rather than paying vendors on the sub...

Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring remittance of federal funds directly to subrecipients, rather than paying vendors on the subrecipient's behalf. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective October 1, 2025, all subrecipients were notified that payments would be made only to them, requiring them to directly pay their contractors and vendors. Name(s) of the contact person(s) responsible for corrective action: Lee McKenzie, OARN Grant Manager Planned completion date for corrective action plan: October 1, 2025

View Audit 390474

Finding 1176622 (2025-005)

Material Weakness 2025

Oregon Association of Relief Nurseries

OR

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring the review and approval of performance, with such review and approval clearly documented. Ex...

Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring the review and approval of performance, with such review and approval clearly documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective January 1, 2026, the Executive Director will review a PDF copy and document approval via email of OARN's Semi-Annual Progress Reports prior to uploading into the EHB. Name(s) of the contact person(s) responsible for corrective action: Kendra Jones, Executive Director Planned completion date for corrective action plan: January 1, 2026

View Audit 390474

Finding 1176614 (2025-002)

Material Weakness 2025

Village of Fairmont

NE

Internal Control / Segregation of Duties HUD Housing Programs

The Village has discussed the finding but must consider the cost of adequate segregation of duties when determining the use of tax money.

View Audit 390438

Finding 1176608 (2025-002)

Material Weakness 2025

Rushmore Electric Power Cooperative, Inc.

SD

Questioned Costs Subrecipient Monitoring Reporting

Finding 2025-002: Internal Controls over Compliance Responsible Individuals: Mark Miller, Accounting Manager Corrective Action Plan: Management is currently implementing review procedures and proper oversight of compliance. Anticipated Completion Date: 2026

View Audit 390424

Finding 1176607 (2025-001)

Material Weakness 2025

Allegheny College

PA

Questioned Costs Student Financial Aid Reporting

Finding 2025-001 The College concurs with the audit finding that students who withdrew at the conclusion of the fall 2024 semester were not reported to the National Student Loan Data System (NSLDS) within the required 60-day reporting timeframe. This occurred as a result of two primary factors: (1) ...

Finding 2025-001 The College concurs with the audit finding that students who withdrew at the conclusion of the fall 2024 semester were not reported to the National Student Loan Data System (NSLDS) within the required 60-day reporting timeframe. This occurred as a result of two primary factors: (1) the enrollment reporting schedule with the National Student Clearinghouse was outdated, and (2) the 60-day reporting requirement was not clearly defined within Allegheny’s internal processes. Allegheny recognizes the importance of timely and accurate reporting of students’ enrollment status to NSLDS. Enrollment rosters and updated enrollment statuses are regularly reported to NSLDS to ensure that changes affecting loan repayment obligations and in-school deferment eligibility are accurately reflected within the Department of Education’s records. The College is committed to strengthening its procedures to ensure continued compliance with federal reporting requirements. The College will continue to adhere to NSLDS reporting processes and required timelines. Through enhanced collaboration among the Financial Aid, Registrar’s, and Provost’s Offices, Allegheny will fully align and formalize enrollment reporting procedures. The College will review, verify, and update reporting schedules to ensure accuracy and compliance with applicable requirements. Specifically, the College will annually review its enrollment reporting schedule with the National Student Clearinghouse to ensure that enrollment data is transmitted to the National Student Loan Data System (NSLDS) at least once every 60 calendar days, in accordance with federal reporting requirements. For students who notify the College of their intent to leave at the upcoming conclusion of a semester, the College will report the student as enrolled on the final enrollment report for that term and will then manually update the student's enrollment status to withdrawn within a few days of the report’s submission, rather than waiting for the next scheduled enrollment transmission, to ensure timely and accurate reporting. Allegheny College will implement quarterly review of processes established to ensure compliance. This proactive approach will ensure ongoing compliance with federal regulations. In addition, Allegheny College is developing a secondary review process for each enrollment report submission to identify students with recent or pending enrollment status changes. This review will serve as a quality control check to ensure that students whose enrollment status has changed since the prior reporting period are accurately identified and updated, thereby strengthening oversight and ensuring timely and compliant reporting to NSLDS.

View Audit 390423

Finding 1176600 (2025-001)

Material Weakness 2025

Triton Regional School District

MA

Questioned Costs Eligibility School Nutrition Programs § 200.437

Corrective Action Plan Finding 2025-001 Condition: A journal entry was tested during the compliance audit that reclassified $50,000 of employee health costs to the school lunch fund that did not include any documentation of the costs charged to the school lunch fund and how they were allocated. Corr...

Corrective Action Plan Finding 2025-001 Condition: A journal entry was tested during the compliance audit that reclassified $50,000 of employee health costs to the school lunch fund that did not include any documentation of the costs charged to the school lunch fund and how they were allocated. Corrective Action Planned: Effective July 1, 2025, the District began to implement a structured and documented cost allocation process for employee healthcare expenses attributable to the Food Services Department. Beginning in FY26: • Charges will be processed monthly to ensure transparency, consistency, and proper budget tracking. Anticipated Completion Date: Ongoing Contact: Richard Poor, Director of Finance & Operations

View Audit 390416

Finding 1176580 (2025-004)

Material Weakness 2025

McDowell County

NC

Eligibility Internal Control / Segregation of Duties Questioned Costs

McDowell County Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: Finding 2025-004 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Comp...

McDowell County Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: Finding 2025-004 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Findings 2025-004 also apply to State requirements and State Awards. Lynn Freeman, Medicaid Program Manager We will provide refresher trainings on household composition, electronic income/resource matches, Request for information requirements, and timely recertifications, with weekly sessions on new policy changes. Medicaid management will collaborate with upper management on solutions to enhance quality control capacity and address staffing constraints. This will include the backlog from the Hurricane Helene-related statewide recertification pause by prioritizing workload distribution. Monthly reviews will continue to be conducted to meet state-mandated requirements, with continued focus on strengthening controls. All required trainings will be completed by November 30, 2025. Section IV - State Award Findings and Question Costs Alison Bell, Finance Officer The 2024 audit report was delayed due to the County's audit firm experiencing a significant cybersecurity incident between October 2024 and February 2025; fieldwork had been completed in October however the financials could not be finished timely and subsequently the data collection was filed late. The audit firm has accepted full responsibility for the delay and informed the County that they would not longer provided audit services to counties. McDowell County issued requests for proposals to all firms qualified to perform county audits for fiscal year 2025 and intends to submit their data collection timely moving forward. June 30, 2026 Section III - Federal Award Findings and Question Costs 161

View Audit 390382

Finding 1176579 (2025-010)

Material Weakness 2025

Johnson C. Smith University

NC

Internal Control / Segregation of Duties Questioned Costs Period of Performance

Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and programregulations. The University continues to enhance its internal controls, policies and procedures toensure the appropriate documentation to support is maintained. Primary Control Enha...

Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and programregulations. The University continues to enhance its internal controls, policies and procedures toensure the appropriate documentation to support is maintained. Primary Control Enhancements. During the next Annual Performance Report (APR) reporting cycle, the AVP for Student Affairs, TRIO and Well-being as well as the respective TRIO program director will correct the inaccurately reported Project Entry Date and First Date of Postsecondary Enrollment for affected participants. These data elements are editable within the APR system and will be updated to align with official institutional and program records. Supporting Controls and Training. To support ongoing compliance, the Federal TRIO Programs have strengthened internal controls and will continue to conduct annual reviews of policies, procedures, and internal controls to ensure alignment with federal regulations and grant administration best practices. To ensure consistent implementation, monthly staff trainings are conducted using the TRIO General Guidelines. In addition, TRIO staff will continue to participate in local and national professional development opportunities to enhance grant management knowledge and standardize practices related to program administration and federal reporting. To ensure all APR reports are accurate moving forward, all APR reports will be completed prior to the deadline and the TRIO staff along with GSPAR will review for accuracy and completeness. Monitoring and Quality Assurance. To further strengthen compliance efforts, the AVP for Student Affairs, TRIO, and Well-being developed a comprehensive TRIO General Guidelines resource for program personnel. The TRIO General Guidelines will be updated to include new JCSU policies that relate to TRIO program management. Informed by Johnson C. Smith University institutional policies, federal TRIO regulations, and best practices from peer institutions, the guide addresses grant administration, record-keeping, participant eligibility, program services, fiscal management, personnel, and travel. TRIO personnel, in collaboration with the Assistant Vice President (AVP) for Student Affairs, TRIO, and Well-being, will continue to conduct regular reviews of participant files and program records to verify data accuracy and regulatory compliance prior to federal reporting. Sustained Oversight. The university will engage in continuous monitoring and evaluation to assess the effectiveness of these corrective actions, identify opportunities for improvement, and maintain full compliance with all applicable regulatory requirements. Anticipated Completion Date: June 2026

View Audit 390365

Finding 1176574 (2025-008)

Material Weakness 2025

Johnson C. Smith University

NC

Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking

Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and program regulations. The University continues to enhance its internal controls, policies, and procedures to ensure the appropriate documentation to support is maintained, and to ensure tha...

Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and program regulations. The University continues to enhance its internal controls, policies, and procedures to ensure the appropriate documentation to support is maintained, and to ensure that level of effort is appropriately documented and reported. To this end the University enlisted the support of Moore & Van Allen and associates law firm to support in developing enhanced policies, procedures, and training modules to support an increased level of compliance support. Moore & Van Allen is a wellrespected international law firm that specializes in reporting compliance and compliance training.To address the specific audit concerns Moore & Van Allen in conjunction with the JCSU executive cabinet, Government Sponsored Programs, the President and Board of Trustees to develop these policies, supporting procedures and training modules. These policies have been approved as of the January 15, 2026 Board of Trustees meeting: Time and Effort Reporting Policy, Government- Sponsored Equipment and Property Management Policy, Post-Award Management Policy, Grant Records Management Policy and Revised Extra Compensation for Faculty and Staff Policy. The level of effort reporting process has been modified to a consistent reporting for all campus awards. Level of effort reports are done by academic term, and the reports are due within 60 days following the end of the term. The Office of Government Sponsored Programs (“GSPAR”) has implemented monitoring and tracking measures to all reports are captured and completed according to federal guidelines. A system of multiple reviews has been implemented to help in reducing errors in reporting and increase efficiency in timeliness of the reports. Additionally, GSPAR intends to work closely with the Human Resources division to ensure accurate and efficient Time and Effort reporting. To address this concern, the Payroll unit has been reorganized into the Business and Finance Office to streamline communication and time and effort report fidelity between Payroll and GSPAR. In addition, the University mandated participation in compliance training for all faculty and staff; participants are required to submit an acknowledgment that they participated in the training and are aware of the compliance requirements. The mandatory training will occur annually for the university and all new grant award recipients will receive this training as part of their grant startup process. All GSPAR employees will also participate in training related to time and effort and allowable costs compliance, annually. Specific to the TRIO programs, as the result of a re-organization in February 2025 the University created a new position: Assistant Vice President (AVP) for Student Affairs, TRIO, and Well-being. This role will oversee Time and Effort Reporting, Annual Performance Report submissions, and financial transactions, ensuring accuracy and adherence to all relevant policies, regulations, and procedures. Additionally, this position will support professional development initiatives to enhance grant management and compliance. The AVP will also support university efforts to conduct regular program reviews to ensure proper documentation supporting TRIO eligibility and adherence to program requirements. To improve program knowledge and standardize practices, TRIO personnel will continue engaging in professional development offered locally and nationally. Internally, the TRIO Leadership Team (TRIO Project Directors and SVP of Student Enrollment & Retention Management) established TRIO Professional Development Day, a two-day training designed specifically for JCSU TRIO staff. These sessions provide guidance on university policies, financial compliance, Time and Effort reporting, effective record-keeping, and data management. The event also includes a roundtable discussion to promote collaboration and shared learning across programs. In addition, the TRIO Leadership Team will continue to explore best practices from high-functioning TRIO programs. To enhance communication and strengthen internal controls, the TRIO Leadership Team implemented monthly TRIO Program meetings. These meetings, involving TRIO Project Directors and the Senior Vice President of Strategic Enrollment and Retention Management, facilitate discussions on compliance, streamline processes, and support policy development. Additionally, the TRIO Leadership Team established monthly interdepartmental meetings among TRIO programs, the Division of Government Sponsored Programs and Research, and the Division of Business and Finance to further ensure alignment with institutional and federal requirements. Human Resources will also participate in future meetings to review Time and Effort Reporting procedures. TRIO Project Directors maintain ongoing communication with the Department of Education Program Officer, seeking written guidance on allowable costs, staffing adjustments, and fund reallocations, when necessary. Continuous monitoring and evaluation will ensure the effectiveness of these corrective actions, allowing the university to identify areas for ongoing improvement and maintain full compliance with all regulatory requirements Anticipated Completion Date: December 2026

View Audit 390365

Finding 1176568 (2025-007)

Material Weakness 2025

Johnson C. Smith University

NC

Student Financial Aid Internal Control / Segregation of Duties Special Tests & Provisions

Corrective Action Plan: To address the deficiencies identified in Finding 2025-008, the University has implemented and continues to strengthen a Registrar-led corrective action framework focused on improving the accuracy, timeliness, and oversight of Campus-Level and Program-Level enrollment reporti...

Corrective Action Plan: To address the deficiencies identified in Finding 2025-008, the University has implemented and continues to strengthen a Registrar-led corrective action framework focused on improving the accuracy, timeliness, and oversight of Campus-Level and Program-Level enrollment reporting to the National Student Loan Data System (NSLDS). Primary Control Enhancements. The University has engaged Strata Information Group (SIG) to support validation and configuration of enrollment reporting functionality within Ellucian Colleague. This engagement assists the Registrar’s Office in ensuring that enrollment status changes, credential completions, and program-level data are transmitted accurately through established reporting processes. Responsibility for enrollment reporting remains with the Office of the Registrar, with SIG serving in a technical advisory capacity. The Office of the Registrar will establish a structured enrollment reporting cadence, including submission of enrollment files on a bimonthly basis. This reporting schedule will ensure timely identification and reporting of enrollment status changes in compliance with federal requirements and reduce reliance on ad hoc or event-driven reporting. Supporting Controls and Training. To further strengthen upstream data integrity, the Registrar’s Office will implement enrollment governance controls, including restricting late graduation applications and limiting major declarations to designated academic periods. These controls reduce late-cycle data changes that previously contributed to reporting inconsistencies. Monitoring and Quality Assurance. The Office of the Registrar has institutionalized a formal quality assurance calendar requiring enrollment reporting reviews at least twice per semester. These reviews validate the accuracy and timeliness of Campus-Level and Program-Level enrollment data reported to the National Student Clearinghouse (NSC) and, by extension, NSLDS. As part of this monitoring framework, the Registrar’s Office will conduct periodic sampling of reported enrollment records to confirm compliance with reporting timelines and verify the effectiveness of enrollment reporting controls. Sustained Oversight. Any discrepancies identified through quality assurance reviews will be documented, corrected, and evaluated to inform process refinement and prevent recurrence. To support reconciliation and data validation, the Registrar’s Office will meet monthly with the Office of Data Analytics to compare enrollment data within Ellucian Colleague to downstream reporting outputs. Anticipated Completion Date: June 2026

View Audit 390365

Finding 1176566 (2025-006)

Material Weakness 2025

Johnson C. Smith University

NC

Student Financial Aid Internal Control / Segregation of Duties Questioned Costs

Corrective Action Plan: To address the deficiencies identified in Finding 2025-006, The Offices of Student Accounts and Financial Aid offices (“the Offices”) will improve coordination and communication regarding the timing of fund transfers and refund disbursements. The Offices have established a sc...

Corrective Action Plan: To address the deficiencies identified in Finding 2025-006, The Offices of Student Accounts and Financial Aid offices (“the Offices”) will improve coordination and communication regarding the timing of fund transfers and refund disbursements. The Offices have established a schedule to begin the refund process 10 calendar days of the credit balance creation date to ensure compliance with the 14-day federal requirement. A written processing calendar has been established to track key deadlines and responsibilities. These actions establish preventive controls to ensure all Title IV credit balances are refunded within the federally required timeframe and to prevent recurrence. Ongoing monitoring of this process will ensure the University issues Title IV refunds within 14 days of the credit balance being applied to the student’s account. Anticipated Completion Date: December 2026

View Audit 390365

Finding 1176563 (2025-005)

Material Weakness 2025

Johnson C. Smith University

NC

Student Financial Aid Internal Control / Segregation of Duties Special Tests & Provisions

Corrective Action Plan: To address the deficiencies identified in Finding 2025-005, the University has implemented and continues to strengthen a comprehensive corrective action framework focused on automating Return of Title IV (R2T4) processing, clarifying cross-functional responsibilities, enforci...

Corrective Action Plan: To address the deficiencies identified in Finding 2025-005, the University has implemented and continues to strengthen a comprehensive corrective action framework focused on automating Return of Title IV (R2T4) processing, clarifying cross-functional responsibilities, enforcing withdrawal data integrity, and institutionalizing quality assurance and supervisory oversight. Primary Control Enhancements. Ellucian Colleague has been configured to automate R2T4 calculations and prevent post-withdrawal disbursements without documented authorization, supported by system-generated audit trails. Supporting Controls and Training. Controls governing withdrawal determination have been strengthened, including required reporting of last date of attendance as a part of grade submission and faculty training to support accurate withdrawal data. This requirement strengthens the integrity of withdrawal data, supports accurate determination of official and unofficial withdrawal dates, and ensures that R2T4 calculations are based on verified enrollment activity. The University has clarified and formalized cross-functional responsibilities related to withdrawal determination and R2T4 processing. Controls now ensure structured communication between academic units, the Office of the Registrar, and the Office of Financial Aid, with defined ownership for initiating, calculating, reviewing, and completing R2T4 determinations. Monitoring and Quality Assurance. To ensure accuracy and timeliness, the University has implemented a secondary review process for all R2T4 calculations. Initial calculations completed in Ellucian Colleague are independently validated using the Return of Title IV calculation tools within the Common Origination and Disbursement (COD) system. This secondary calculation serves as a quality control measure prior to final processing and fund return. In addition, R2T4 activity is subject to periodic quality assurance reviews, including monitoring of calculation timeliness, authorization documentation, and fund return deadlines. Sustained Oversight. Any discrepancies identified by QA reviews are documented, corrected, and reviewed to inform process improvements and staff training. Supervisory oversight is in place to ensure compliance with federal timelines and calculation requirements. Anticipated Completion Date: August 2026

View Audit 390365

Finding 1176560 (2025-004)

Material Weakness 2025

Johnson C. Smith University

NC

Internal Control / Segregation of Duties Questioned Costs Student Financial Aid

Corrective Action Plan: To address the deficiencies identified in Finding 2025-004, the University has implemented and continues to enhance corrective actions focused on automating loan disbursement notifications, standardizing notification content and timing, strengthening documentation and audit t...

Corrective Action Plan: To address the deficiencies identified in Finding 2025-004, the University has implemented and continues to enhance corrective actions focused on automating loan disbursement notifications, standardizing notification content and timing, strengthening documentation and audit trails, and institutionalizing quality assurance oversight to ensure sustained compliance with federal notification requirements. Primary Control Enhancements. Loan disbursement notifications to the student for Subsidized, Unsubsidized, and Graduate PLUS Loans are now system-generated through Ellucian Colleague, providing automated delivery and a documented audit trail. Notifications are issued upon disbursement processing and delivered through system-supported modalities, including electronic communication and student portal updates. Ellucian Colleague retains a system-generated audit trail documenting the timing and content of each notification, strengthening the University’s ability to demonstrate compliance with federal requirements. This system-based approach eliminates reliance on third-party notification tools previously used and brings direct control of notification sequencing, content, and documentation within the University’s financial aid infrastructure. Supporting Controls and Training. The University has revised the Parent PLUS Loan notification process to ensure that required disbursement information—including the date, amount, and type of loan—is provided directly within the notification communication. While Parent PLUS notifications currently require initiation through a controlled manual process, procedures have been amended to ensure timely issuance, content accuracy, and supervisory oversight during this interim period. The University is actively working with the Ellucian Colleague implementation team to further automate Parent PLUS Loan disbursement notifications and eliminate manual triggering. Until full automation is achieved, documented procedures and quality assurance reviews will serve as compensating controls to ensure compliance with notification timing and content requirements. Monitoring and Quality Assurance. The University established and maintains a formal quality assurance framework to monitor loan disbursement notifications. A quality assurance calendar requires reviews at least twice per semester to confirm that notifications are issued within required regulatory timeframes, include all required elements, and are sent to the appropriate recipient (student or parent). As part of ongoing monitoring, the University has conducted multiple quality assurance reviews of loan disbursement notifications. These reviews have demonstrated improved compliance with notification timing and content requirements while also identifying isolated system sequencing issues that were promptly addressed through configuration updates and enhanced scheduling controls within Ellucian Colleague. Sustained Oversight. Any discrepancies identified through quality assurance reviews are documented, corrected, and evaluated to inform process refinement, system configuration, and staff training. Anticipated Completion Date: September 2026

View Audit 390365

Finding 1176559 (2025-003)

Material Weakness 2025

Johnson C. Smith University

NC

Student Financial Aid Internal Control / Segregation of Duties

Corrective Action Plan: To address the deficiency identified in Finding 2025-003, the University has implemented and is continuing to formalize corrective actions focused on strengthening award notification sequencing, automating required communications, and ensuring a verifiable audit trail prior t...

Corrective Action Plan: To address the deficiency identified in Finding 2025-003, the University has implemented and is continuing to formalize corrective actions focused on strengthening award notification sequencing, automating required communications, and ensuring a verifiable audit trail prior to the disbursement of Title IV funds. Primary Control Enhancements. With the assistance of Financial Aid Services (FAS), Ellucian Colleague has been configured to automate award notification generation upon completion of student packaging, creating a system-generated audit trail that documents notification timing relative to disbursement. This automation ensures that award notifications are issued prior to disbursement activity and creates a system-generated audit trail documenting the timing and issuance of the notification. Supporting Controls and Training. Financial Aid staff receive ongoing system and compliance training to reinforce proper sequencing of notifications and disbursements. Monitoring and Quality Assurance. Routine quality assurance reviews confirm that award notifications are issued and documented prior to disbursement, with exceptions documented and corrected. Sustained Oversight. Any exceptions identified will be reviewed, documented, and corrected to ensure sustained compliance. Anticipated Completion Date: June 2026

View Audit 390365

Finding 1176555 (2025-002)

Material Weakness 2025

Johnson C. Smith University

NC

Student Financial Aid Reporting Internal Control / Segregation of Duties

Corrective Action Plan: To address the deficiencies identified in Finding 2025-002, the University has implemented and is continuing to formalize a comprehensive corrective action strategy focused on strengthening disbursement scheduling, improving system integration, institutionalizing reconciliati...

Corrective Action Plan: To address the deficiencies identified in Finding 2025-002, the University has implemented and is continuing to formalize a comprehensive corrective action strategy focused on strengthening disbursement scheduling, improving system integration, institutionalizing reconciliation and quality assurance processes, and enhancing cross-functional oversight of COD reporting. Primary Control Enhancements. A standardized disbursement and reporting calendar has been established, and system integration between Ellucian Colleague and Jenzabar has been strengthened to improve consistency of cost-of-attendance and disbursement data transmitted to COD. For the 2025–2026 academic year, the Office of Financial Aid and the Office of Student Accounts are disbursing Title IV aid on the second and fourth Tuesday of each month. This schedule has been jointly approved and will continue to be followed by both departments to ensure consistency between disbursement activity and COD reporting. Supporting Controls and Training. Staff participate in targeted training related to COD reporting and cash management through NASFAA and FSA to reinforce knowledge of reporting timelines and requirements. Monitoring and Quality Assurance. A formal financial aid compliance calendar has been developed and institutionalized, outlining required quality assurance (QA) reviews by month, identifying responsible departments, and requiring documented supervisory sign-off. Reviews of COD reporting timelines are conducted twice per semester, and any discrepancies identified are documented, reviewed, and resolved in a timely manner. A systematic monthly reconciliation process has been instituted and is maintained involving the Office of Financial Aid, the Office of Student Accounts, and Budgets & Grants Accounting to ensure consistency across internal systems and COD reporting. Sustained Oversight. Any discrepancies identified through reconciliation are documented, communicated to relevant departments, and resolved, with formal supervisory sign-off required from the Assistant Director of Financial Aid and the Director of Budgets & Grants Accounting. In addition, Financial Aid maintains standing bi-weekly coordination meetings with Student Accounts and Business Office staff to support ongoing alignment related to Title IV disbursement activity and COD reporting timelines. Anticipated Completion Date: June 2026

View Audit 390365

Finding 1176531 (2025-014)

Material Weakness 2025

State of West Virginia

WV

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to m...

2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to maintain continual monitoring of conducted Annual Unannounced Monitoring Visits required under 45 CFR §98.42(b)(2)(i)(B). Within the tracking spreadsheet, detailed information is input from our documentation system PATH COGNOS Report PCC-PLI 1080. Information includes Provider Name, Provider Number, Provider Type, Specialist Name, and columns for visits conducted and visits not yet conducted. To provide an overall year-to-date calculation of monthly totals/percentages, a Yearly Summary tab is included in the spreadsheet for a quick reference analysis to provide an additional method of tracking visits. As the monthly totals and percentages change, the data updates on the monthly tabs and the Yearly Summary tab. Program Managers have implemented individual efforts to track visits conducted by specialists. The PCC-PLI 1080 report is distributed twice per month by PM II to each Program Manager for review. Specialists have been instructed to include completed annual unannounced monitoring visits on monthly report data, which can then be compared with the PCC-PLI-1080 reports. Additionally, a tracking system has been implemented that requires specialists to pre-plan annual unannounced visits for the 2026 calendar year to ensure visits are completed.

View Audit 390319

Corrective Action Plans

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