Corrective Action Plans

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Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-001 – Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, ...
Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-001 – Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan Campus Status Matt Smith, College Registrar, will work with Tom Cote, NSC Enrollment Reporting Consultant, to adjust the enrollment report produced by PeopleSoft. With this change, PeopleSoft will report a student's campus-level enrollment as withdrawn when they withdraw in the middle of a semester instead of leaving them as less than half-time. Program Status Matt Smith, College Registrar, and Riley Niemand, Director of Financial Aid, will use the NSLDS Enrollment Error Report to reconcile what is being reported from NSC to NSLDS to ensure it is accurate. Timing Campus Status Matt Smith is currently working with Tom Cote to make these changes and work will be completed by the end of May 2025. Program Status Matt Smith and Riley Niemand will have this reconciliation implemented by the end of June 2025. Sincerely, S. Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to thi...
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to third-party service platform transitions, two delays were related to students experiencing hardship (homelessness and mental health emergencies) and internal documentation gaps. Effect: Noncompliance with R2T4 deadlines may result in program findings, increased liabilities, and recurring audit scrutiny if unresolved. Corrective Actions for R2T4: 6. R2T4 Tracker Implementation o Action: Launch a live R2T4 tracker in Campus Café, flagged by withdrawal status and showing days remaining until the 45-day deadline. o Due Date: May 15, 2025 o Lead: Registrar, Business Office, Financial Aid Lead 7. Case Ownership Assignment Protocol o Action: Assign R2T4 responsibility to ECM and Business Office, written timelines and escalation criteria. o Due Date: May 15, 2025 o Lead: Executive Director 8. R2T4 Checklist & Escalation Framework o Action: Finalize a standardized checklist for all R2T4 cases including withdrawal date, calculation verification, fund return confirmation, and dual review. o Due Date: May 15, 2025 o Lead: Operations Manager 9. Quarterly R2T4 Audit o Action: Conduct quarterly compliance audits on all R2T4 files and include findings in compliance reports. o Due Date: First audit by June 30, 2025 o Lead: Compliance Officer 10. Emergency Circumstance Protocol o Action: Document a formal protocol for handling R2T4 cases with student hardship that allows internal escalation, verification, and documentation of exception handling. o Due Date: July 1, 2025 o Lead: Executive Director Monitoring Plan: Compliance will provide a quarterly report on R2T4 timeliness to the Executive Director. Any case that nears 35 days will be auto escalated for executive intervention.
Finding #1: Delayed or Incomplete Enrollment Reporting Criteria: Per 34 CFR 685.309(b), institutions must report student enrollment status changes (withdrawals, graduations, leaves of absence) within 30 days of determination or every 60 days using a consistent reporting schedule. Condition: Enrollme...
Finding #1: Delayed or Incomplete Enrollment Reporting Criteria: Per 34 CFR 685.309(b), institutions must report student enrollment status changes (withdrawals, graduations, leaves of absence) within 30 days of determination or every 60 days using a consistent reporting schedule. Condition: Enrollment changes for several students were not reported to NSLDS within the required timelines. Delays resulted from third-party servicer (ECM) processing issues, gaps in cross-verification, and lack of internal triggers for mid-enrollment aid recipients. Effect: Untimely reporting may result in incorrect loan repayment statuses for borrowers and may trigger additional oversight by the Department of Education. Corrective Actions for Enrollment Reporting: 1. Shared Operational Calendar with Alerts o Action: Expand the institutional calendar to include enrollment reporting cycles with automated alerts 15 and 5 days before reporting deadlines. o Due Date: May 15, 2025 o Lead: Registrar 2. Internal Monthly Cross-Verification Audit o Action: Reconcile Campus Café enrollment records with ECM NSLDS batch confirmations monthly to catch and correct discrepancies. o Due Date: Begins May 2025, ongoing o Lead: Compliance Officer 3. Enhanced Title IV Status Tracking o Action: Update batch tracker template to log when students begin receiving Title IV aid after initial enrollment, with clear notation requirements. o Due Date: May 15, 2025, Ongoing o Lead: Registrar 4. Targeted Staff Training o Action: Deliver internal training on accurate Title IV status coding and enrollment reporting procedures to Registrar and Business Office teams. o Due Date: May 15, 2025 o Lead: Executive Director & Registrar 5. Bi-Monthly Enrollment Reporting Review o Action: Conduct a compliance review every 8 weeks to assess reporting timeliness and documentation quality. o Due Date: Begins May 2025 o Lead: Compliance Officer Monitoring Plan: Compliance team will issue bi-monthly reports to the Executive Director summarizing reporting performance and identifying risk patterns.
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding...
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the review of program reporting and campus reporting, the college will identify the cause for the data error. The college will explore the impact of branch campuses and the potential to shift to a single college reporting model. The following specific steps will be completed. 1. Identify and Analyze the Issues 2. Root Cause Analysis 3. Corrective Measures 4. Automation: Implement automated checks and balances to ensure data integrity before files are processed and sent. Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Cheryl Eldredge, College Associate Dean for Registrar and Master Schedule Planned completion date for corrective action plan: December 31, 2026
Views of Responsible Officials: All Astraea staff members are required to complete timesheets. Astraea’s internal processes were reviewed and overhauled in December 2021 (midway through FY2022) with department heads determining how their direct reports would spend time on various Astraea work stream...
Views of Responsible Officials: All Astraea staff members are required to complete timesheets. Astraea’s internal processes were reviewed and overhauled in December 2021 (midway through FY2022) with department heads determining how their direct reports would spend time on various Astraea work streams and projects. This information is detailed in a level of effort (LOE) spreadsheet tracked against timesheets and budgets regularly. However, the processes for instituting regular updates to the LOE spreadsheet and timesheet allocations remained time-consuming and highly manual in FY2023 – which we believe resulted in misallocations. Astraea is currently reviewing internal processes to ensure, 1) that review and revision of the LOE spreadsheet and timesheet allocations can happen in a timely manner with less administrative burden, and 2) allowance of a more detailed review of the payroll allocation approval and entry process. As of January 1, 2025, a new finance system was implemented allowing for greater sophistication, consistency and automation of these processes. We do not expect to see this finding upon completion of our FY25 audit.
The Utility will adopt a policy to ensure that all vendors and contracts paid with federal awards, are not suspended or disbarred by verifying it on the SAM website.
The Utility will adopt a policy to ensure that all vendors and contracts paid with federal awards, are not suspended or disbarred by verifying it on the SAM website.
We acknowledge that system configuration errors in the Student Financial Aid Department resulted in the disbursement of federal direct student loans exceeding aggregate loan limits for three students. The University reimbursed the over-awarded funds to the Department of Education in February 2025 an...
We acknowledge that system configuration errors in the Student Financial Aid Department resulted in the disbursement of federal direct student loans exceeding aggregate loan limits for three students. The University reimbursed the over-awarded funds to the Department of Education in February 2025 and adjusted the affected students' accounts accordingly. To address these deficiencies and ensure compliance with aggregate loan limits, the University has reviewed the financial aid management system to identify and correct configuration errors. Furthermore, the University will assign an independent reviewer to monitor loan disbursements monthly, ensuring they remain within aggregate loan limits and promptly addressing any discrepancies.
View Audit 356516 Questioned Costs: $1
Management Response: Management concurs with the finding and will reconcile the College’s disbursement records with the federal COD system and correct all errors on a monthly basis.
Management Response: Management concurs with the finding and will reconcile the College’s disbursement records with the federal COD system and correct all errors on a monthly basis.
View Audit 356480 Questioned Costs: $1
Management Response: Going forward, all students who withdraw from the College will be forwarded to the financial aid team to review whether a student is still eligible for the full funding of the specific semester in question or whether funding needs to be returned based on the withdrawal date. If ...
Management Response: Going forward, all students who withdraw from the College will be forwarded to the financial aid team to review whether a student is still eligible for the full funding of the specific semester in question or whether funding needs to be returned based on the withdrawal date. If it is deemed that funds need to be returned, the Bursar will provide the financial aid team with a copy of the student charges for that period and the Registrar will provide proof of the withdrawal date and the financial aid team will determine the amount of funding that needs to be returned. Financial aid will then complete the return through the student's account and notify the Controller and VP of Finance and Administration to process the return to G5.
View Audit 356480 Questioned Costs: $1
Management Response: The College concurs with the finding and is in the process of implementing a policy when satisfactory academic progress is run, students will be notified via mail or email of their academic standing. Students who are suspended will have an opportunity to appeal their suspension....
Management Response: The College concurs with the finding and is in the process of implementing a policy when satisfactory academic progress is run, students will be notified via mail or email of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.
Management Response: The College acknowledges and concurs with the finding. The College is in the process of implementing changes to the student information systems and related process to accommodate both the internal enrollment polices and required reporting statuses, and enhances monitoring proces...
Management Response: The College acknowledges and concurs with the finding. The College is in the process of implementing changes to the student information systems and related process to accommodate both the internal enrollment polices and required reporting statuses, and enhances monitoring processes to ensure the integrity and punctuality of data reported to the NSLDS.
Finding 2024-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Federal Financial Assistance Listing Number: 93.829 Finding Summary: During audit testing of reimbursement...
Finding 2024-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Federal Financial Assistance Listing Number: 93.829 Finding Summary: During audit testing of reimbursement requests, there was no documentation available for the review and approval procedures performed. Responsible Individuals: Joshua Duame, Fractional CFO Corrective Action Plan: Management agrees with the finding. There was turnover in staff and the prior CFO did not keep a record of his review over cash management. In the future, management will ensure that documentation of the approval process for reimbursement is kept. Anticipated Completion Date: 5/1/2025
Finding 560529 (2024-001)
Significant Deficiency 2024
The SPS Federal Grants Manual has been updated to consider this recommendation and the federal suspension and debarment requirements.
The SPS Federal Grants Manual has been updated to consider this recommendation and the federal suspension and debarment requirements.
Research and Development Cluster – Department of Energy Publication Compliance Requirements Views of Responsible Officials: EPRI agrees with this finding. We are developing corrective actions to create a centralized archive of government publications, and a process with an owner to ensure that gover...
Research and Development Cluster – Department of Energy Publication Compliance Requirements Views of Responsible Officials: EPRI agrees with this finding. We are developing corrective actions to create a centralized archive of government publications, and a process with an owner to ensure that government publications are reviewed and approved before they are released outside of EPRI. Expected Completion Date: June 30, 2025, including a catch-up review of all 2025 government publications. Contact Person Jennifer Hill, Government Controller
Management agrees with the above finding and has implemented a plan to reduce expenses and increase cash flows going forward. Specifically, we have outlined the following steps that we are taking as an organization to get back on track:  Cash flow is monitored weekly and forecasted on a rolling 8-w...
Management agrees with the above finding and has implemented a plan to reduce expenses and increase cash flows going forward. Specifically, we have outlined the following steps that we are taking as an organization to get back on track:  Cash flow is monitored weekly and forecasted on a rolling 8-week basis.  Existing vendor contracts were reviewed and changes made to reduce expenses moving forward into the 2025 fiscal year. Contracts are continually evaluated for potential cost savings.  We implemented a robust and detailed budget development process to continue cost-cutting measures into 2025 and beyond. Directors are accountable to their budget guidelines to ensure expenses are appropriately managed.  The 36-unit Independent Living expansion project remains a high priority. The model home construction is nearing completion, and new homes are expected to commence construction in 2025. The sale and occupancy of these units are expected to generate substantial future cash flows for the organization.  We continue to prioritize aggressive staff recruitment to eliminate agency staffing needs. While the organization has already seen a steady decline in contract staff utilization, it is our goal to fully eliminate agency staffing in 2025.  An administrative restructuring completed in 2024 allowed the organization to reduce its leadership by 2 positions. Additionally, a review of staffing ratios identified areas of excess staffing, to which the organization responded by utilizing fewer contract staff. The organization is committed to further reducing labor costs appropriately, primarily in supervisory staff through attrition moving forward.  Management enacted a progressive plan to increase census in each of its business lines to increase revenue, utilizing focused marketing efforts and referral partnerships.
Planned Corrective Action: ● Since learning of this issue, our Food Service Director has manually checked every application. ● Our Food Service Director is rewriting our policy to include reviewing at least 2 applications per week for any week in which 2 or more applications are received through Pay...
Planned Corrective Action: ● Since learning of this issue, our Food Service Director has manually checked every application. ● Our Food Service Director is rewriting our policy to include reviewing at least 2 applications per week for any week in which 2 or more applications are received through PaySchools. We intend to fully implement this policy with the start of the 2025-26 school year. ● This new policy will allow us to randomly verify applications throughout the year to be sure that all Federal guidelines are being met. Anticipated Completion Date: In Process Responsible Contact Person: Tim Walker, Treasurer
Views of Responsible Officials: Timesheets are now being submitted with every payroll to the proper supervisor for review and signatures.
Views of Responsible Officials: Timesheets are now being submitted with every payroll to the proper supervisor for review and signatures.
Views of Responsible Officials: DREF is in the process of hiring a part-time CFO to review all financial reports.
Views of Responsible Officials: DREF is in the process of hiring a part-time CFO to review all financial reports.
We concur with the auditors finding as follows: During the years ended July 31, 2019, 2020, 2021, 2022, 2023 and 2024, management did not fully repay the loan advanced from the reserve for replacements upon receipt of the Section 8 subsidy that was outstanding at July 31, 2018. The loan in the amo...
We concur with the auditors finding as follows: During the years ended July 31, 2019, 2020, 2021, 2022, 2023 and 2024, management did not fully repay the loan advanced from the reserve for replacements upon receipt of the Section 8 subsidy that was outstanding at July 31, 2018. The loan in the amount of $19,337 is deemed to be an unauthorized distribution. As of July 31, 2024, the amount due to the reserve for replacement has been partially repaid. The remaining amount due as of July 31, 2024 is $9,669. b. Action(s) Taken or Planned on the Finding As of July 31, 2024, two installments were made in the amount of $4,834 for a total of $9,668. This has been deposited by the lender Walker & Dunlop to the repairs for reserve escrow account. The balance now owed on the repayment comes to $9,669. The updated loan agreement signed was signed on 3/14/24 to repay the balance of the loan borrowed to the Lender a payment of $100 each month until the loan is repaid in full.
2024-002 Allowable Indirect Costs Federal Agencies: U.S. Department of Health and Human Services, and U.S. Department of the Treasury Program Titles and ALN Numbers: 1.ALN #93.566: Refugee and Entrant Assistance State/Replacement Designee Administered Programs2.ALN #93.676: Unaccompanied Children Pr...
2024-002 Allowable Indirect Costs Federal Agencies: U.S. Department of Health and Human Services, and U.S. Department of the Treasury Program Titles and ALN Numbers: 1.ALN #93.566: Refugee and Entrant Assistance State/Replacement Designee Administered Programs2.ALN #93.676: Unaccompanied Children Program3.ALN #21.027: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Grant Numbers: U.S. Department of Health and Human Services: 1. Refugee and Entrant Assistance State Administered Programs/Refugee andEntrantAssistance State / Replacement Designee Administered Programs: a. Florida Department of Children and Families: Comprehensive Refugee Services -Leon County (Tallahassee), Florida (ALN 93.566, award number LK207) b. Maryland Department of Human Resources MORA Office: i. Refugee Transitional Cash Assistance (RTCA) Maryland (ALN93.566,award number FIA/RTCA-23-507) ii. Refugee Transitional Cash Assistance (RTCA) Maryland (ALN93.566,award number FIA/RTCA-24-507) iii. Extended Case Management Program (ALN 93.566, award numberFIA/ECMP-24-514) c.New York State Office of Temporary & Disability Assistance: Refugee SchoolImpact Program (RSIP) (ALN 93.566, award numberTDA01 C00948GG-3410000) d. Catholic Charities, Diocese of Fort Worth: i. Refugee Cash Assistance (ALN 93.566, award number FFY2024-22536C-CMA) ii. Refugee Support Services (RSS) Program (ALN 93.566, award numberFFY2024-27927C-RSS) iii. Refugee Cash and Medical Assistance (CMA) Program (ALN 93.566,awardnumber FFY2024-27927C-CMA) iv. Refugee Support Services (RSS) Program - Afghan SupplementalAppropriations (ASA) (ALN 93.566, award number FFY2024-27927C-ASA-RSS) e. Colorado Department of Human Services: REACH: Cash and MedicalAssistance(ALN 93.566, award number 24 IHGA 184529) 2. Unaccompanied Children Program/Heartland Human Care Services:UnaccompaniedMinors (ALN 93.676, award number 90ZU0358-03-00) U.S. Department of Treasury: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds: 1. City of Phoenix: ARPA Funding Round 2 (ALN 21.027, award number 157893-0 FE) 2. Maricopa County (Arizona): Refugee Relocation Program - RA Services (ALN 21.027,award number C-73-23-083-X-00) Contact Person: Rick Estridge, Controller, rick.estridge@rescue.org, (443)890-0915 Corrective Action: The following corrective action will be taken to update and strengthen internal controls to ensure indirect costs are applied correctly and any correction is completed within the applicable fiscal year: 1. A communication will be released to all IRC finance staff to share this exception and reinforce the requirement that: i) indirect cost rates, and any applicable exclusions are provided to the consolidation unit at the start of each award, ii) Indirect cost calculation are reviewed and reconciled between the invoice and the General ledger. 2. A tool will be released to be used by all field finance leads monthly, before the submission of invoices, and at the closure of each award to verify the accuracy of the indirect cost calculation. Any differences identified will be adjusted. 3. The awards financial management unit and the regional finance teams will apply the above tool on a quarterly basis for additional oversight and monitoring for any discrepancies. Anticipated Completion Date: September 30, 2025
Delays in Financial Reporting Recommendation: The County should look at increasing the amount of experienced finance staff to help facilitate year-end closing procedures and the preparation of its basic financial statements. Because the basic financial statements are the responsibility of the County...
Delays in Financial Reporting Recommendation: The County should look at increasing the amount of experienced finance staff to help facilitate year-end closing procedures and the preparation of its basic financial statements. Because the basic financial statements are the responsibility of the County, it is in its best interest to closely monitor the accounting process to ensure that financial position and operating results are accurately and timely reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor-Controller’s office is currently in the process of providing additional training to its staff to further develop their technical knowledge, and to assess internal processes over year-end closing processes and the preparation of financial statements in order to accurately update financial records and in a timely manner. Name of the contact person responsible for corrective action: Gina Will Planned completion date for corrective action plan: March 31, 2026
Finding 560103 (2024-004)
Significant Deficiency 2024
Internal Control Over Eligibility Department of Human Services Medical Assistance – Assistance Listing No. 93.778 Recommendation: We recommend the county implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and...
Internal Control Over Eligibility Department of Human Services Medical Assistance – Assistance Listing No. 93.778 Recommendation: We recommend the county implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in maxis and issues are followed up in a timely matter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County will continue to train staff to ensure they are aware of the requirements. Names of the contact person responsible for corrective action: Denise Gaida, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2025
Finding 2024-003 – U.S. Department of Agriculture – Community Facilities Loan and Grant, Assistance Listing # 10.766 Following the hiring of a permanent president, the new CFO has developed a quarterly reporting template to ensure compliance with the U.S. Department of Agriculture (USDA) reporting r...
Finding 2024-003 – U.S. Department of Agriculture – Community Facilities Loan and Grant, Assistance Listing # 10.766 Following the hiring of a permanent president, the new CFO has developed a quarterly reporting template to ensure compliance with the U.S. Department of Agriculture (USDA) reporting requirements. The CFO submits the completed reports to the USDA on a quarterly basis and maintains regular communication with USDA representatives to address any concerns or clarifications regarding compliance.
Finding 2024-002 – Student Financial Aid Cluster, Assistance Listing # 84.063 and 84.268 Limestone University utilizes Jenzabar software to extract and report enrollment data to the National Student Clearinghouse (NSC). However, in some instances, the data reported was incorrect. Since the occurrenc...
Finding 2024-002 – Student Financial Aid Cluster, Assistance Listing # 84.063 and 84.268 Limestone University utilizes Jenzabar software to extract and report enrollment data to the National Student Clearinghouse (NSC). However, in some instances, the data reported was incorrect. Since the occurrence of this issue, the University hired a new Registrar in August 2024. After reviewing the findings, the Registrar implemented the use of the NSC Edit Student Data Records window, in addition to the NSC Edit Registration Transactions window. This change allows a special status on the NSC Edit Student Data Records window to override the status on the Registration Transactions window, providing more precise monitoring of withdrawal dates and ensuring the accuracy and timeliness of the data reported to NSC. To ensure ongoing accuracy, the Registrar now reports enrollment status changes to NSC on a monthly basis. Additionally, the University reviewed the students identified in the findings, along with other students who had the same status (withdrawn) and made adjustments as necessary to ensure that all student data was accurately reported.
Corrective Action: We will create an end of year checklist to ensure timely submission of data collection form in the future. As of 4/21/2025, all Federal Audit Clearinghouse data collection forms have been submitted.
Corrective Action: We will create an end of year checklist to ensure timely submission of data collection form in the future. As of 4/21/2025, all Federal Audit Clearinghouse data collection forms have been submitted.
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