Corrective Action Plans

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Finding 2024-002 – HOME Loans Affordable Period Monitoring Management’s Response or Department’s Response Management concurs with the finding. Views of Responsible Officials and Corrective Action The Department will provide training to staff on HOME monitoring requirements, updating policies a...
Finding 2024-002 – HOME Loans Affordable Period Monitoring Management’s Response or Department’s Response Management concurs with the finding. Views of Responsible Officials and Corrective Action The Department will provide training to staff on HOME monitoring requirements, updating policies and procedures, as necessary, to address all current regulatory requirements. The Department’s multifamily monitoring for all projects in the HOME period of affordability will be completed prior to June 30, 2025. As part of the monitoring process, the Department will document all records requiring annual or semi-annual oversight and review for compliance with HOME requirements. Should the monitoring result in any findings requiring corrective action, the Department will ensure all findings are addressed by September 30, 2025. Anticipated Completion Date May 2025 Contact Information of Responsible Official Name: Augustine Ramirez Title: Division Manager, DPWP Community Development Division Phone: 559-600-4266
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Child Welfare Services (“CWS”) recognizes that licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the recor...
Views of Responding Officials: The Department agrees with the finding and will implement corrective action. Child Welfare Services (“CWS”) recognizes that licensing case files from neighbor islands (Maui, West Hawaii, and Kauai) came late or not at all, and this lack of ability to review the records significantly contributed to the errors. Moving forward, CWS will ensure easier records identification by geographical location and begin the neighbor island’s audits first, allowing extra time for records travel to review site. CWS also notes that additional communication and information sharing with auditors would have been helpful to ensure understanding of expectations prior to on site audit. The communications requested would resemble a pre audit information sharing call, an on site audit entry meeting with key agency staff, and an audit exit conference to discuss findings before the final report is generated. Corrective Action Taken or Planned: 1. CWS staff will be informed of the audit findings and corrective action plan, emphasizing the importance of: A. Providing requested records in advance of the audit, B. Diligent compliance with policies and procedures, C. Supervisor coaching, support and review of records/documents for completeness, D. The impact of individual unit records maintenance performance on the outcome of the audit and this corrective action plan. 2. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. Staff will: A. Continue to ensure staff are securing the Adoption Assistance and Legal Guardian permanency assistance forms that provide notice for age changes and payment increases. B. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated, and ensuring it is filed in eligibility record. C. Locate or reprint and file missing “Certificate of Approvals.” D. Locate missing clearances in records not provided for review or re run them if not located in records reviewed. Please note: Not all clearances are secured prior to placement; FBI clearances come later and are NOT required prior to placement in a “provisionally licensed” home. E. Administrators to work with courts to ensure court orders contain the required language and are secured in a timely fashion. i. Secure missing termination of parental rights order. ii. Secure court order supporting “reasonable efforts.” iii. Secure missing police protective custody documentation or voluntary foster custody agreement for three cases. F. For young person(s) in Imua Kakou (“IK”) who turned 18 while in care. i. CWS will secure a letter for the record, from the school that the young person is attending, which notes when the young person is expected to graduate. ii. Work with IK providers and IK liaison to make sure logs and meeting minutes are in SHAKA. iii. Document (reason for) continuation of monthly subsidy payments after youth turned 18. 3. CWS has identified the Eligibility Unit (“FPPEU”) record as the primary record for audits with the Licensing record and other case files as secondary. 4. Unit staffs (Licensing, CWS, and FPPEU) who manage cases identified with errors in this audit will be retrained, ensuring familiarity with grant requirements and related policies and procedures. A. The FPPEU Administrator and supervisors will review the eligibility unit record checklist and ensure use of checklist will lead to a complete record containing all required documentation. B. FPPEU staff will review error records identified in this audit, following checklist and secure missing documentation, update inaccurate information and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Document the qualifying need for Difficulty of Care (“DOC”) determination for the records, showing how DOC was calculated. iii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. C. The Licensing Unit Section Administrator and supervisors will review error records identified in this audit, secure missing documentation, update inaccurate information, and verify that all necessary documentation is present. i. Staff will be given coaching/supervisory support to correctly complete documentation. ii. Case specific audit findings and corrective actions taken will be noted in each record where there was a finding. 5. The identified errors and the related corrective action steps proposed above will be reviewed by CWS Administrators, staff supervisors, and the Management Information Compliance Unit (“MICU”) within 90 days to ensure missing documentation has been secured and/or properly noted in record. A. MICU staff will audit records to verify that corrective actions have been completed for case specific audit findings. This includes verifying that records contain a note explaining updated information or information gathered due to audit. B. MICU will work with Branch Administrators, Section Administrators, Social Services Assistants (“SSA”) and program personnel to ensure file updates with completion of missing information. C. MICU will verify accuracy of DOC calculations for case specific errors noted in this audit, while supervisors will verify accuracy of DOC calculations on an ongoing basis. 6. As CWS implements this corrective action plan and monitors the results, the action steps proposed in 1 5 may be modified, based on input from CWS Administrators or exploration groups with line staff who complete this documentation. 7. In preparation for future audits, CWS will update the file identification and secure transport process as follows: A. MICU will send a separate email for records request to each neighbor island, identifying only their records, rather than sending a joint, multi-island, records request. B. The records request email sent by MICU will include a submittal deadline that will accommodate extra time for secured travel of records between islands to ensure all records arrive on time. C. MICU and Branch will review records submitted, ensuring that all records are available to the auditors for review. Completion Date: On going Responding Official(s): Kisha C. Raby, Social Services Division Program Development Administrator; Tonia Mahi, Social Services Division Assistant Child Welfare Services Branch Administrator
View Audit 350226 Questioned Costs: $1
2024-003 Views of Responsible Officials and Planned Corrective Actions: Management agrees with the audit recommendations and remains committed to strengthening grant management and financial oversight. This year’s challenges in grant reconciliation stemmed from overlapping prior-year FTA claims is...
2024-003 Views of Responsible Officials and Planned Corrective Actions: Management agrees with the audit recommendations and remains committed to strengthening grant management and financial oversight. This year’s challenges in grant reconciliation stemmed from overlapping prior-year FTA claims issues, pending grant amendments, and limited time, as noted in Finding 2024-002. Additionally, the increased complexity of federal grants following the pandemic required adjustments to allocation methods and financial reporting. To address these issues, staff has refined internal processes, including improving worksheets, enhancing review procedures, and consolidating grant data into a single summary sheet for better tracking. The 2024 FTA Triennial Review acknowledged these improvements, and the corrective action plan was considered sufficient, with recommendations to closely monitor grant activity and update the worksheets as necessary. Moving forward, staff will continue formalizing procedures for expense allocation, improve reconciliation processes, and ensure grant expenditures align with available funding. Grant tracking will provide a clearer overview of balances, deadlines, and remaining funds. The Finance department also adjusted its billing practices to reconcile expenses earlier in the reporting cycle, allowing sufficient time for review and claim adjustments. Regarding the overclaimed amounts of $183,548 and $175,143, staff will work with the FTA to determine whether repayment is required or if the funds can be applied to future eligible expenses. These efforts will strengthen compliance, improve accuracy in financial reporting, and overall grant management. Responsible Party: Director of Finance & Administration Implementation Date: Ongoing; full implementation expected by December 31, 2025
Finding Number: 2024 – 003 – Reporting Grantor: Department of Labor (DOL)-Office of Disability Employment Policy (ODEP) Program Name: Disability Employment Policy Development Award Name: Disability Employment Policy Development Award Number: 23475OD000001-01-00 (passthrough ID 24-SA-053-3203) Assist...
Finding Number: 2024 – 003 – Reporting Grantor: Department of Labor (DOL)-Office of Disability Employment Policy (ODEP) Program Name: Disability Employment Policy Development Award Name: Disability Employment Policy Development Award Number: 23475OD000001-01-00 (passthrough ID 24-SA-053-3203) Assistance Listing Titles: Disability Employment Policy Development Assistance Listing Numbers: 17.720 Award Year: Fiscal Year 2024 Passthrough Entity: The Council of State Governments Corrective Action Plan: Cornell acknowledges that performance reports for this award were not filed timely. To address this omission the university will reinforce the importance of timely reporting during routine training and update sessions in the coming year and remind departments that these requirements are stated in the award documents and the research administration system. Responsible individual: Mary-Margaret Klempa, Senior Director, Office of Sponsored Programs
Finding Number: 2024 – 002 – Notification prior to disbursement of Title IV funds Grantor: Department of Education Program Name: Student Financial Assistance Cluster Award Name: Federal Pell Grant Program Award Numbers: not applicable Assistance Listing Titles: Federal Pell Grant Program Assistance ...
Finding Number: 2024 – 002 – Notification prior to disbursement of Title IV funds Grantor: Department of Education Program Name: Student Financial Assistance Cluster Award Name: Federal Pell Grant Program Award Numbers: not applicable Assistance Listing Titles: Federal Pell Grant Program Assistance Listing Numbers: 84.063 Award Year: Fiscal Year 2024 Passthrough Entity: various Corrective Action Plan: Cornell acknowledges that Title IV financial aid was disbursed before a student received their official aid offer due to a manual processing error. To prevent this issue in the future, Cornell implemented a new Peoplesoft system control called a “user edit message” in August 2024. • The new user edit message prevents Title IV and other financial aid disbursements until the system has generated and sent an official aid offer in August 2024. • The new user edit message is assigned (and cleared, when appropriate) via batch system processes that run prior to daily disbursement processes. • On-demand queries were also developed to monitor performance of the control as well as to proactively identify and address any currently unknown circumstances that may result in similar outcomes. • The new controls were implemented in all currently active aid years and will remain as standard controls in future years. Responsible individual: Kevin J. Jensen, Executive Director, Office of Financial Aid and Student Employment
Finding Reference: 2024-012 - SFA Reporting (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: Jackson State University has established a formalized procedure, effective immediately, to ensure the accurac...
Finding Reference: 2024-012 - SFA Reporting (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: Jackson State University has established a formalized procedure, effective immediately, to ensure the accuracy and compliance of the annual Fiscal Operations Report and Application to Participate (FISAP). As part of this process, a FISAP Review Committee will be created to oversee the review of the FISAP and all supporting documentation at least three weeks before the official submission deadline. The FISAP will be prepared by the Executive Director of Student Financial Aid Services and Scholarships, who will also gather and compile all necessary supporting documentation. This completed report, along with all relevant data, will then be submitted to the FISAP Review Committee for thorough examination. The committee will verify the accuracy of all figures and ensure that the supporting documents meet FISAP compliance requirements. Submission of the FISAP will only proceed once the FISAP Review Committee has reached a consensus confirming the accuracy and completeness of the report. This structured review process will help safeguard against errors, enhance compliance, and ensure that JSU meets all federal reporting standards. Estimated Completion Date: September 1, 2025
Finding Reference: 2024-011 - Program Income, Ryan White (UMMC) Responsible Official: Mustafa Khawaja, Interim Director of Post-Award Corrective Action Planned: Based on feedback received from a Sponsor-led site visit in 2024, UMMC practices and policies are appropriately aligned with the intent of ...
Finding Reference: 2024-011 - Program Income, Ryan White (UMMC) Responsible Official: Mustafa Khawaja, Interim Director of Post-Award Corrective Action Planned: Based on feedback received from a Sponsor-led site visit in 2024, UMMC practices and policies are appropriately aligned with the intent of the program. UMMC will make efforts to ensure that all practices and policies are clearly documented and evaluated periodically. Estimated Completion Date: June 30, 2025
Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (ASU) Responsible Official: Kisha Bond, Registrar Corrective Action Planned: ASU must report enrollment status for students in the NSLDS database within a 60-day window. ASU reported the enrollment status for the ...
Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (ASU) Responsible Official: Kisha Bond, Registrar Corrective Action Planned: ASU must report enrollment status for students in the NSLDS database within a 60-day window. ASU reported the enrollment status for the students but not within 60 days. Moving forward, ASU will monitor the activity for the NSLDS database and submit student enrollment data on a timely basis. Estimated Completion Date: August 29, 2025 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (JSU) Responsible Official: Ms. Lakesha Tubbs, Registrar Corrective Action Planned: Jackson State University will implement a multi-tiered enrollment reporting schedule to enhance accuracy and prevent certification and enrollment reporting errors. Effective immediately, JSU will submit an initial enrollment reporting file to the National Student Clearinghouse at the beginning of each term. Additionally, two subsequent enrollment reports will be submitted—one at midterm and another within ten (10) days of final grade publication at the end of the term. To ensure consistency, transparency, and alignment across university departments, JSU will establish an Enrollment Reporting Oversight Committee composed of representatives from key university offices. This committee will convene quarterly throughout the academic year to review enrollment reporting processes, address potential discrepancies, and implement best practices. By fostering collaboration amongst stakeholders, JSU will ensure compliance, accuracy, and efficiency in enrollment reporting. Estimated Completion Date: May 9, 2025 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (MSU) Responsible Official: Emily Shaw, University Registrar Corrective Action Planned: In addition to reporting in a timely manner to National Student Clearinghouse, MSU will also begin to monitor NSC’s reports to NSLDS. Estimated Completion Date: June 15, 2025 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (MVSU) Responsible Official: Jeffrey Loggins, Director of Student Records Corrective Action Planned: The Office of Student Records will review the schedule submission dates for enrollment reporting to the National Student Clearinghouse to ensure compliance with certifying student enrollment within 60-day timeframe from program enrollment effective date. Additionally, enrollment reporting data will be carefully reviewed in an effort to avoid future enrollment errors. Moreover, this may include adding an additional date to report enrollment data during semesters. Estimated Completion Date: February 15, 2026 Finding Reference: 2024-005 - SFA Special Tests and Provisions - Enrollment Reporting (UMMC) Responsible Official: Emily Cole, Executive Director Office of Enrollment Management Corrective Action Planned: As an internal control measure, the Office of Enrollment Management has identified two individuals to verify all enrollment changes are appropriately captured in the National Student Loan Data System (NSLDS) within the 60-day time period. The Senior Record Specialist and Senior Enrollment Data Specialist will review pertinent records in the NSLDS monthly to verify all information has been correctly conveyed from the National Student Clearinghouse System. Estimated Completion Date: Effective immediately
Finding Reference: 2024-003 - SFA COD Reporting (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU reconciles Pell and federal direct student loans to COD monthly. The reconciliation is done timely, and ASU will continue to reconcile and pr...
Finding Reference: 2024-003 - SFA COD Reporting (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU reconciles Pell and federal direct student loans to COD monthly. The reconciliation is done timely, and ASU will continue to reconcile and provide evidence of review. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships; Ms. Lakesha Tubbs, Registrar; Adrienne Walls, Bursar Corrective Action Planned: In previous years, Jackson State University has extended the purge and registration dates to better serve a high number of students from underrepresented communities and low-income backgrounds, ensuring that they have the opportunity to complete the enrollment process. However, this practice has led to inaccurate reporting of enrollment dates. Moving forward, Jackson State University will work with new, continuing, and readmit students beginning in April 2025 through the start of the Fall 2025 semester on August 18, 2025, to ensure all enrollment materials are completed before the beginning of each term. As part of this effort, Jackson State University has redesigned its new student orientation process with the goal of ensuring students are completely registered before arriving on campus for the fall semester. Within this new model, a dedicated position has been created for First-Time Freshmen to establish proactive outreach and education regarding costs to students and families. The redesigned orientation process places a strong emphasis on First-Time Freshmen, guaranteeing they receive the necessary guidance and support to successfully transition into college life. Additionally, the university will enforce enrollment deadline dates to prevent inaccurate enrollment data and eliminate errors in disbursement records. In addition to enhancing the student enrollment process, JSU is also taking steps to strengthen financial accountability. Furthermore, Jackson State University’s Financial Aid Office, in coordination with its Business Office, will begin holding regularly scheduled reconciliation meetings at the end of each month. These meetings will ensure that the amounts disbursed on both sides align and that figures from both departments match what has been drawn down and either paid out or returned to the U.S. Department of Education Common Origination and Disbursement (COD). Both departments will also utilize an institutional reconciliation document to add another layer of control and prevent errors. These strategic improvements reflect Jackson State University’s ongoing commitment to compliance, operational efficiency, and student success. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The internal control procedures will initiate a reconciliation of disbursement dates against COD data. Estimated Completion Date: September 30, 2025 Finding Reference: 2024-003 - SFA COD Reporting (UMMC) Responsible Official: Davita Weary, Director of Student Financial Aid Corrective Action Planned: Reconciliations will be reviewed with Kelly Dismuke, Director of Finance Operations, on a monthly basis. Estimated Completion Date: March 26, 2025 Finding Reference: 2024-003 - SFA COD Reporting (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: USM reconciles Pell and DL monthly. Copies of reconciliations are saved in a shared drive and can be made available upon request. The reconciliations will be reviewed on a monthly basis by the Financial Aid Assistant Director (Alanna McDonald) and Director (David Williamson), and the Bursar (Barbara Madison) when necessary. Estimated Completion Date: March 17, 2025
Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: The Jackson State University Division of Financial Aid has implemented a co...
Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: The Jackson State University Division of Financial Aid has implemented a comprehensive training initiative to strengthen compliance, improve accuracy, and enhance staff proficiency in federal student aid verification. As of May 7, 2024, ongoing training has commenced for all financial aid staff on the 2024-2025 verification process and required documentation. Additionally, beginning April 4, 2025, the department will launch continuous training on verification procedures and Federal Student Aid compliance to ensure staff remains informed of regulatory updates and best practices. To further enhance accuracy and accountability, the department will collaborate with the Department of Information Technology (IT) to develop internal error reports that proactively identify discrepancies in student records. An internal checklist will also be implemented to ensure that each student selected for verification by the U.S. Department of Education has submitted all required documentation. This checklist must be reviewed and signed off by the Executive Director of Student Financial Aid Services and Scholarships before final processing. As part of the department’s transition to a more automated verification process, JSU will integrate Campus-Logic, powered by Ellucian, to streamline operations and reduce manual errors. Comprehensive training sessions will be conducted to ensure financial aid staff are proficient in using the platform. Additionally, an internal checklist within Campus-Logic will be established to facilitate structured review and compliance tracking. A final verification review will be conducted by the Executive Director of Student Financial Aid Services and Scholarships to uphold accuracy and federal compliance, ultimately mitigating errors and improving audit outcomes. Estimated Completion Date: December 19, 2025 Finding Reference: 2024-008 - SFA Special Tests and Provisions - Verification (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The verification process will ensure all student data is accurate and corrected by staff. Estimated Completion Date: September 30, 2025
Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (ASU) Responsible Official: Charlette Mock, Director of Accounting Corrective Action Planned: ASU uses a servicer to deliver ...
Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (ASU) Responsible Official: Charlette Mock, Director of Accounting Corrective Action Planned: ASU uses a servicer to deliver credit balance to students. The contract with the servicer should have been uploaded to the Dept of Ed database. Since the audit finding, the contract has been uploaded. ASU will upload the contract timely going forward. Estimated Completion Date: Effective Immediately Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (MVSU) Responsible Official: Mrs. Brittney Manuel-Carpenter, Account Receivable Supervisor Corrective Action Planned: MVSU acknowledged the findings of reference 2024-06 SFA-Special Test- Using a Servicer to Deliver Title IV Credit Balances. MVSU acknowledges that the servicer contract is uploaded to the Department of Education database and is available for viewing. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-006: SFA Special Tests and Provisions - Using a Servicer or Financial Institution to Deliver Title IV Credit Balances to a Card or Other Access Device (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: University will contact the Department of Education Cash Management to correct the URL link. While the link was broken on the Cash Management site it was active on the USM Business Services website: https://www.usm.edu/business-services/refunds.php and is continually maintained on their site. Estimated Completion Date: April 1, 2025
Finding Reference: 2024-004 - SFA Special Tests and Provisions - GLBA (MVSU) Responsible Official: Dameon A. Shaw, Vice President for Information Technology Corrective Actions Planned: 1. Develop a Comprehensive Information Security Program to ensure MVSU has a full information security program that...
Finding Reference: 2024-004 - SFA Special Tests and Provisions - GLBA (MVSU) Responsible Official: Dameon A. Shaw, Vice President for Information Technology Corrective Actions Planned: 1. Develop a Comprehensive Information Security Program to ensure MVSU has a full information security program that addresses all 7 required elements of the GLBA regulations: • Review GLBA Requirements: Conduct a thorough review of the Gramm-Leach-Bliley Act (GLBA) regulations to understand the 7 required elements. - Completed • Gap Analysis: A gap analysis has been performed to identify missing elements in the current information security program. - Completed • Program Development: Develop and implement policies and procedures to address the identified gaps. This includes administrative, technical, and physical safeguards. - In Progress • Training: Provide training to staff on the new policies and procedures to ensure compliance and proper implementation. - Planning • vCISO Support: Leverage the expertise of the newly hired virtual Chief Information Security Officer (vCISO) to guide the development and implementation of the information security program. - In Progress 2. Conduct a Comprehensive Risk Assessment to identify and address significant gaps in the risk assessment process: • Risk Assessment Framework: Establish a risk assessment framework that aligns with GLBA requirements. - In Progress • Identify Risks: Identify potential risks to the confidentiality, integrity, and availability of customer information. – In Progress • Evaluate Controls: Assess the effectiveness of existing controls and identify areas for improvement. – In Progress • Mitigation Plan: Develop a risk mitigation plan to address identified vulnerabilities and implement appropriate controls. - Planning • vCISO Support: Utilize the vCISO's expertise to ensure a thorough and effective risk assessment process. – In Progress 3. Monitoring and Continuous Improvement to ensure ongoing compliance and continuous improvement of the information security program: • Regular Audits: Conduct regular audits to ensure compliance with GLBA regulations and the effectiveness of the information security program. – Planning • Feedback Mechanism: Establish a feedback mechanism to gather input from staff and stakeholders on the effectiveness of the program. - Planning • Update Policies: Periodically review and update policies and procedures to address emerging threats and changes in regulations. – In Progress • vCISO Support: Engage the vCISO in monitoring and continuous improvement efforts to maintain high standards of information security. – In Progress 4. Reporting and Accountability to ensure accountability and transparency in the implementation of the corrective action plan: • Assign Responsibility: Assign responsibility for the implementation of the corrective action plan to a dedicated team or individual. - Planning • Progress Reports: Provide regular progress reports to senior management and stakeholders on the implementation of the corrective action plan. - Planning • Documentation: Maintain thorough documentation of all actions taken to address the identified issues. - Planning • vCISO Support: Include the vCISO in reporting and accountability processes to ensure expert oversight and guidance. – In Progress By following this corrective action plan and leveraging the expertise of the vCISO, MVSU can address the deficiencies in its information security program and risk assessment process, ensuring compliance with GLBA regulations and protecting customer information effectively. Estimated Completion Date: November 30, 2025
Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU will ensure that post withdrawal aid that could have been disbursed will be disbursed timely unless...
Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (ASU) Responsible Official: Debra Reynolds, Assistant Director of Financial Aid Corrective Action Planned: ASU will ensure that post withdrawal aid that could have been disbursed will be disbursed timely unless the student requests otherwise. Estimated Completion Date: June 30, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director of Student Financial Aid Services and Scholarships Corrective Action Planned: Jackson State University has examined the error and has implemented targeted training on the Return of Title IV (R2T4) process. This training focuses on accurately determining break days and performing the required calculations to ensure precision and compliance. To reinforce these efforts, the university will continue to provide quarterly training and cross-training opportunities for staff, ensuring a comprehensive understanding of R2T4 policies and procedures. To further strengthen accuracy, an additional internal review process has been established within the financial aid office. This review will be conducted by the Executive Director of Financial Aid, who will oversee calculations until the responsibility is designated to another team member with demonstrated expertise in R2T4 processing. These corrective measures will enhance the accuracy of R2T4 calculations, ensure compliance with federal regulations, and improve overall financial aid operations at Jackson State University. Estimated Completion Date: May 2, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (MSU) Responsible Official: Lori Ball Executive Director for Financial Aid and Scholarship Corrective Action Planned: Our interpretation of the regulation was that if classes were held on weekends before or after the 5-day break, the weekend days were not counted, only the week itself (Monday- Friday) and the weekend afterwards. Classes started back the next Monday so we used 7 days. If we do not have classes on Saturday before spring break, we are now counting 9 days. Estimated Completion Date: March 15, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (MVSU) Responsible Official: Angela Fant, Director of Financial Aid Corrective Action Planned: The internal control procedures have been updated to incorporate a nine-day break. The refund of funds to the Department of Education will be processed upon completion of the necessary calculations. Estimated Completion Date: September 30, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (UM) Responsible Official: Mr. Eduardo Prieto, Vice Chancellor for Enrollment Management Corrective Action Planned: The University of Mississippi’s Office of Financial Aid has an existing process for next-level supervisor review of all Return of Title IV (R2T4) calculations. To further strengthen compliance, future R2T4 reviews will also include any documentation used to determine the date of withdrawal. While it is believed that communication with instructors was accurate, messaging will be refined to clarify which activities cannot be used to document academic engagement (e.g., simply logging into the online system). Additional scrutiny will be applied when determining the last date of attendance for online courses, and instructors will be contacted for clarification as needed. The Office of Financial Aid has also established a unit to enhance compliance through internal reviews of various processes, including R2T4. Although not all R2T4 calculations will be selected for examination, sample evaluations will provide an additional level of oversight. Additionally, a transition to Ellucian’s Banner system is planned for the 2026-2027 academic year, requiring instructors to report the last date of attendance for all F grades at the time of grade entry. This change will help minimize ambiguity regarding unofficial withdrawals. Estimated Completion Date: April 1, 2025 Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (UMMC) Responsible Official: Coralisa Williams, Senior Financial Aid Advisor Corrective Action Planned: Processing procedure has been updated to state the use of the “last date in class” from the academic calendar published in the UMMC Bulletin to ensure consistent and correct processing of R2T4. Estimated Completion Date: Effective immediately (has reviewed current R2T4 for accuracy) Finding Reference: 2024-002 - SFA Special Tests and Provisions - Return of Title IV Funds (USM) Responsible Official: David Williamson, Director of Financial Aid Corrective Action Planned: The university included the Friday commencement day as last day of the term. Our reasoning is that some students are still completing assignments, tests, and class projects through the day of commencement. The financial aid office will verify the number of class days with the registrar office before each semester to ensure all class days are included in the award period. The student with the possible post-withdrawal disbursement withdrew prior to our census and all institutional charges were reversed and we could not verify that the student actually attended any of their classes. Effective February 3, 2025, institutions are exempt from performing an R2T4 calculation in this situation. Amend § 668.22(a)(2)(ii)(A)(6) to exempt institutions from performing an R2T4 calculation if: (1) a student is treated as never having begun attendance; (2) the institution returns all title IV, HEA assistance disbursed to the student for that payment period or period of enrollment; (3) the institution refunds all institutional charges to the student for that payment period or period of enrollment; and (4) the institution writes off or cancels any payment period or period of enrollment balance owed by the student to the institution due to the institution's returning of title IV, HEA funds to the Department. Going forward, USM intends to not perform R2T4 calculations for students that meet one of the above exemptions. Other possible post withdrawal disbursement will be tracked, and communication will be sent to students eligible once they are identified and calculated upon withdrawal. Estimated Completion Date: March 17, 2025
View Audit 350191 Questioned Costs: $1
Finding 539640 (2024-005)
Significant Deficiency 2024
Nbcc
CA
xiii. Management Response and Corrective Action Plan: One of the individuals tested was identified as not being enrolled in the audited grant during the audit period. This is correct. The individual was exited from the program in the previous audit period and written documentation was uploaded to d...
xiii. Management Response and Corrective Action Plan: One of the individuals tested was identified as not being enrolled in the audited grant during the audit period. This is correct. The individual was exited from the program in the previous audit period and written documentation was uploaded to demonstrate this. However, the case manager neglected to exit the individual from HMIS during the previous audit period. This has been corrected. No services or funds were provided to this individual following their exit from the program. Our program has a good track record of data compliance and we expect this was an exception and not the rule. Program management will review and train staff again on data compliance during a weekly staff meeting, and will also counsel the involved staff member on the error to ensure there is no similar future error. xiv. Contact Person (s) Responsible for Corrective Action: Cassie Roach, Safe Parking Program Director, croach@sbnbcc.org Joel Goforth, Homeless Services Director, jgoforth@sbnbcc.org xv. Anticipated Completion Date: The anticipated completion date is April 30, 2025.
Finding 539638 (2024-003)
Significant Deficiency 2024
Nbcc
CA
vii. Management Response and Corrective Action Plan: The travel in question involved staff travel to the annual National Alliance to End Homelessness (NAEH) conference. As evidenced by correspondence with HUD AAQ, it has long been established that attending an NAEH conference is an eligible use of ...
vii. Management Response and Corrective Action Plan: The travel in question involved staff travel to the annual National Alliance to End Homelessness (NAEH) conference. As evidenced by correspondence with HUD AAQ, it has long been established that attending an NAEH conference is an eligible use of CoC and ESG grant funds. We perceived the historical general approval to be in alignment with the contract requirement of obtaining written approval for the reimbursement of costs incurred for travel outside the county. All costs submitted for reimbursement were eligible and reasonable expenses. We now understand this historical approval by HUD was not transferrable to this grant and therefore, moving forward, we will secure email approval of travel eligibility for specific grant reimbursement prior to travel. To that end, we have already been in contact with Housing and Community Development (HCD) fiscal staff at Santa Barbara County about a reliable method to secure said approvals in advance moving forward. If travel is not approved for a specific grant, or not obtained prior to travel, other unrestricted income will be utilized for that portion of the travel expenses. viii. Contact Person (s) Responsible for Corrective Action: Kristine Schwarz, Executive Director, kschwarz@sbnbcc.org Victoria Garfield, Grants Administrator, vgarfield@sbnbcc.org ix. Anticipated Completion Date: Staff anticipate attending the annual NAEH conference this year, therefore we will request approval once registration is confirmed and expect to receive approval or rejection from County CD staff by no later than the date of travel, or approximately July 15, 2025.
View Audit 350179 Questioned Costs: $1
Finding 539637 (2024-002)
Significant Deficiency 2024
Nbcc
CA
iv. Management Response and Corrective Action Plan: Program staff allocate their time spent at work each day based on their client load and recurring weekly activities, e.g., case conferencing meetings. Staff must allocate their daily time and activity hours on their timesheets corresponding to the...
iv. Management Response and Corrective Action Plan: Program staff allocate their time spent at work each day based on their client load and recurring weekly activities, e.g., case conferencing meetings. Staff must allocate their daily time and activity hours on their timesheets corresponding to the project/s each client is enrolled in. Leave allocations should reflect each payroll period’s project time and activity actual percentages. Staff must manually record this information on complicated timesheets and consequently errors are made as not all staff are equally administratively adept. While there are multiple levels of review over timesheets, as the company has grown, it has become apparent that NBCC must integrate a more reliable method of always ensuring accurate allocation calculation of regular and leave hours. The expectation was that our new payroll solution provider, Paychex, was going to custom tailor a system that prevented such calculation errors, but this has not been the case thus far. Therefore, NBCC is actively once again researching payroll companies in an effort to find a solution better aligned with our timesheet needs. In the interim, management will work to edit our existing timesheet template to create a more user-friendly timesheet tool that auto-calculates where necessary and as appropriate so as to avoid misallocation. Management will also conduct additional timesheet trainings with staff as necessary. The end goal will be to secure a new payroll solution provider with system functionality that eliminates this kind of human error. v. Contact Person (s) Responsible for Corrective Action: Kristine Schwarz, Executive Director, kschwarz@sbnbcc.org Victoria Garfield, Grants Administration Director, vgarfield@sbnbcc.org Michael Dzierski, Finance Director, mdzierski@sbnbcc.org vi. Anticipated Completion Date: The anticipated completion date of the first step of editing our existing timesheet and retraining all staff as necessary is June 30, 2025. The anticipated completion date of the second step of having an integrated new payroll system with a new payroll solution provider will be dictated by the identification of a new vendor, and the subsequent development and implementation process of the new system, with an estimated completion date of December 31, 2025.
S3800-010: Finding Reference Number 2024-002 S3800-030: Statement of Condition: Our audit procedures revealed that the security deposit cash account was underfunded for nine (9) out of the twelve (12) months tested. Specifically, the required balance for security deposits was not fully met in...
S3800-010: Finding Reference Number 2024-002 S3800-030: Statement of Condition: Our audit procedures revealed that the security deposit cash account was underfunded for nine (9) out of the twelve (12) months tested. Specifically, the required balance for security deposits was not fully met in these months, resulting in a deficiency in the account. Although the funding deficit amounts were not always significant, it is important that the security deposit cash account be fully funded at all times. S3800-080: Auditor Recommendation: We recommend that property management implement a more robust process for monitoring and reconciling the security deposit cash account on a monthly basis. This process should ensure that the account balance is consistently maintained at the required level. Furthermore, management should conduct periodic reviews of the security deposit balances to identify and address any discrepancies promptly. Training for staff involved in managing security deposits should be considered to ensure compliance with HUD regulations and internal policies. FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT (Continued) S3800-010: Finding Reference Number 2024-002 (Continued) S3800-045: Actions Taken or to be Taken: It is management’s policy to fully fund the security deposit account so the balance in cash meets or exceeds the total liability of deposits collected from tenants. Management discussed the importance of reviewing funding monthly with the Project Accountant, and new procedures have been implemented to include a monthly process to compare the security deposit liability to the bank account and fund any shortages to ensure the security deposit bank account is consistently maintained at the required level.
The Registrar’s Office will incorporate the recommendations to fix the deficiency to create and deploy a more timely report to identify students who re-enroll at the College. It should be noted that since the College is implementing this change as early as March 2025, there may be a continuation of ...
The Registrar’s Office will incorporate the recommendations to fix the deficiency to create and deploy a more timely report to identify students who re-enroll at the College. It should be noted that since the College is implementing this change as early as March 2025, there may be a continuation of the deficiency from July 1, 2024 through March 31, 2025.
Finding Number: 2024-002 Planned Corrective Action: The District had an unusually high volume of federal grants related to the CARES Act. There were expenditures planned for these funds; however, due to supply issues with both vendors and materials, other projects had to be substituted for the p...
Finding Number: 2024-002 Planned Corrective Action: The District had an unusually high volume of federal grants related to the CARES Act. There were expenditures planned for these funds; however, due to supply issues with both vendors and materials, other projects had to be substituted for the planned expenditures to meet timing requirements of the grant. It was during this process that the requirements related to the Davis Bacon Act were not followed. Moving forward, staff has gained experience and are more aware of the effects of moving expenditures for grant-related funds. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Jacqueline Webb
View Audit 350140 Questioned Costs: $1
Finding 539593 (2024-001)
Significant Deficiency 2024
Occidental College Corrective Action Plan Finding 2024-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control Over Compliance Explanation of Deficiency: Occidental sent a degree file to the National Student Clearinghouse (NSC) on June 12, 2024. It was...
Occidental College Corrective Action Plan Finding 2024-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control Over Compliance Explanation of Deficiency: Occidental sent a degree file to the National Student Clearinghouse (NSC) on June 12, 2024. It was a sent a week after an enrollment file. The enrollment file had errors which required resolution before the NSC could process the degree file. The enrollment file errors were remedied on June 25, 2024. The degree file also had errors posted on June 26, 2024, and corrected by Occidental on July 29, 2024. Correction Action Plan: The staff member currently responsible for resolving National Student Clearinghouse (NSC) file errors has now been trained in the institutional responsibility to send NSC files on time and to resolve any resulting errors immediately. In additional, the College will soon be hiring an administrative position (currently open) in the Registrar’s Office who will act as Occidental’s main liaison with the NSC. Plans for the new liaison training include both NSC processing as well as the relationship between NSC submissions and the institutional responsibility to report accurate enrollment to the National Student Loan Data System (NSLDS) as required. Training will be conducted by the Registrar with the assistance of the Director of Financial Aid for emphasis on institutional responsibilities as outlined in 34 CFR 685.3096(b). Contact Person Responsible for Corrective Action: James Herr, Occidental College Registrar Anticipated Completion Date: December 12, 2024 (end of Fall semester but before next degree file is sent to NSC)
FINDING 2024-004: US Department of Education and PA Department of Education - COVID-19 Education Stabilization Fund (ESF) - ALN #84.425 - Special Tests and Provisions - Wage Rate Requirements Criteria: In accordance with Uniform Guidance requirements found in Part 3 Section N, "Special Tests and Pro...
FINDING 2024-004: US Department of Education and PA Department of Education - COVID-19 Education Stabilization Fund (ESF) - ALN #84.425 - Special Tests and Provisions - Wage Rate Requirements Criteria: In accordance with Uniform Guidance requirements found in Part 3 Section N, "Special Tests and Provisions" of the Compliance Supplement, all laborers and mechanics employed by contractors or subcontractors to work on construction contracts in excess of $2,000 financed by federal assistance funds must be paid wages not less than the prevailing wages rates established by the Department of Labor (DOL). Nonfederal entities shall include in their construction contracts subject to the Wage Rate Requirements a provision that the contractor or subcontractor comply with those requirements and DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance. Condition: The School District did not have adequate internal control procedures in place to ensure that all laborers and mechanics employed by contractors or subcontractors to work on construction contracts in excess of $2,000 financed by federal assistance funds were paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor. As a result, the School District did not properly notify 1 of the 3 contractors tested of the requirements to comply with the wage rate requirements via the including of a prevailing wage rate clause in the contract between the contractor and the School District, and therefore, the use prevailing wage rates were not determined. Cause: The School District did not have formal procedures in place to ensure that prevailing wage rate requirements were met on all construction projects over $2,000. Effect: The School District was not in compliance with the Special Tests and Provisions - Wage Rate Requirements of the Uniform Guidance. Repeat Finding: No Questioned Costs: Unknown Recommendation: We recommend that the School District revise its purchasing policy to formally reflect the requirements of Special Tests and Provisions - Wage Rate Requirements. Additionally, we recommend that the School District establish procedures to ensure that prevailing wage rate requirements are met for federally funded construction projects over $2,000. Views of Responsible Officials and Planned Corrective Action: The School District agrees with the recommendation. The Business Office will require that projects over $2,000 involving federal must use prevailing wage rates.
View Audit 350127 Questioned Costs: $1
Name ofcontactperson: Julie B. Savino, Associate Vice President of Student Financial Assistance Corrective action: The University remains committed to maintaining compliance with federal requirements and ensuring accurate Free Application for Federal Student Aid (FAFSA) verification. Staff will c...
Name ofcontactperson: Julie B. Savino, Associate Vice President of Student Financial Assistance Corrective action: The University remains committed to maintaining compliance with federal requirements and ensuring accurate Free Application for Federal Student Aid (FAFSA) verification. Staff will continue to receive verification training through internal and external means to ensure the accuracy ofthe verification requirements. To address the identified issues, the University will strengthen verification policies and procedures by adding controls to prevent data entry errors. As part ofthese improvements, a secondary review process will require a Director level staff member to evaluate any Institutional Student Information Record (ISIR) updates or changes before finalizing the Student Aid Index (SAI) (previously known as Estimated Family Contribution EFC). Proposed completion date: April 15, 2025
DCHS has reviewed its procedures and will ensure that suspension and debarement status is documented prior to contracting with a vendor.
DCHS has reviewed its procedures and will ensure that suspension and debarement status is documented prior to contracting with a vendor.
Finding Number: 2024-002 Condition: Organization failed to submit the SF PPR report as of December 31, 2023 by January 30, 2024. Planned Corrective Action: ECDI has created a calendar for deadlines that has been shared between Development, Fiscal, and Program managers to ensure all deadlines are m...
Finding Number: 2024-002 Condition: Organization failed to submit the SF PPR report as of December 31, 2023 by January 30, 2024. Planned Corrective Action: ECDI has created a calendar for deadlines that has been shared between Development, Fiscal, and Program managers to ensure all deadlines are met. Multiple notifications are provided to these parties in advance of due dates. Contact Person Responsible for Corrective Action: Brian Barrett, Hudu Ahmed and Louisa Dallett Completion Date: March 1, 2025
Finding Number: 2024-001 Condition: GBQ identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. Specifically, one employee had salaries and wages allocated to the program in excess of ho...
Finding Number: 2024-001 Condition: GBQ identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. Specifically, one employee had salaries and wages allocated to the program in excess of hours tracked to the program for a selected month. Another employee had an inappropriate wage rate applied to allocated time to the program. Last, two employees had compensation levels allocated to the program in excess of the Executive Level II Salary max amount in effect for the respective period. Planned Corrective Action: ECDI will put additional steps in place in Payroll Review process to ensure reconciliation of payroll charges to actual time records and rates. The organization will modify it's calculations to ensure that pay rates are reflective of the timeframe in question (not for periods before or after). ECDI will update its calculations to include thresholds for Executive pay so they are not entered in excess of approved rates. The company is also exploring technology enhancements so that information from ECDl's Payroll system flows directly into ECDl's Accounting system to limit the chance of errors during extraction from Payroll system and uploading into Accounting system. Contact Person Responsible for Corrective Action: Brian Barrett and Hudu Ahmed. Completion Date: In process
View Audit 350075 Questioned Costs: $1
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