Corrective Action Plans

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FINDING 2025-006 – Federal Direct Loan Eligibility Program Name: Federal Direct Student Loan Program ALN and Program Expenditures: 84.268 ($866,312) Award Number: P268K253315 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $484, net Condition Found: The amount of subsidized Feder...
FINDING 2025-006 – Federal Direct Loan Eligibility Program Name: Federal Direct Student Loan Program ALN and Program Expenditures: 84.268 ($866,312) Award Number: P268K253315 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $484, net Condition Found: The amount of subsidized Federal Direct Loans awarded was incorrect for four of the ten students in our sample that received Federal Direct Loans. In addition, the two of the students was eligible for additional Federal Direct Loan funds. Corrective Action Plan: For the first student, the student was eligible to receive $5,500 of subsidized funds, but only $4,500 was requested. The University gave the student an additional $1,000 of institutional funds to cover the difference in the amount the student was eligible to receive and the amount requested from the Department of Education in December 2025. For the second student, the COD correctly shows the that $5,500 of subsidized aid was disbursed to the student. However, only $4,500 of subsidized loan funds were posted to the student’s account. An institutional scholarship of $1,000 was posted to the student account in December 2025. For the third student, $484 of subsidized loan funds were returned to the Department of Education in December 2025. For the fourth student, the Director of Financial Aid will work with third party administrator to reclassify the subsidized loan funds as unsubsidized loan funds. Anticipated Completion Date: The University anticipates the corrective action being completed by March 31, 2026. Contact Person: Brad Burnett, Director of Financial Aid 405-912-9000
FINDING 2025-005– NSLDS Reporting Program Name: Federal Direct Student Loan Program ALN and Program Expenditures: 84.268 ($866,312) Award Number: P268K253315 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: N/A Condition Found: During our compliance testing, student enrollment sta...
FINDING 2025-005– NSLDS Reporting Program Name: Federal Direct Student Loan Program ALN and Program Expenditures: 84.268 ($866,312) Award Number: P268K253315 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: N/A Condition Found: During our compliance testing, student enrollment status changes were reported to the National Student Loan Database System (“NSLDS”) timely for nine of the seventeen students selected for testing. Corrective Action Plan: A new Student Financial Aid Director was hired in July 2025. The Student Financial Aid Director and Registrar will work together to determine and report student enrollment status changes within the required timeframe to NSLDS. Anticipated Completion Date: The University anticipates the corrective action being completed by March 31, 2026. Contact Person: Brad Burnett, Director of Financial Aid 405-912-9000
FINDING 2025-002 – Exit Interview Program Name: Federal Direct Loan Program ALN and Program Expenditures: 84.268 ($866,312) Award Number: P268K253315 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: N/A Condition Found: Six of the seventeen federal student financial aid recipients...
FINDING 2025-002 – Exit Interview Program Name: Federal Direct Loan Program ALN and Program Expenditures: 84.268 ($866,312) Award Number: P268K253315 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: N/A Condition Found: Six of the seventeen federal student financial aid recipients in our sample did not complete or were not sent exit interview instructions to complete within thirty days of the student ceasing to be enrolled in the University at least half-time. Corrective Action Plan: A new Financial Aid Director was hired in July 2025. The Financial Aid Director will review the students in question to determine if exit instructions were sent after the thirty-day time period. If an exit interview has not already been sent, the Financial Aid will mail exit interview instructions to the students’ home address. In addition, the Director of Financial Aid will work with the third-party administrator to determine which entity is responsible for sending exit interview information to students. Anticipated Completion Date: The University anticipates the corrective action being completed by March 31, 2026. Contact Person: Brad Burnett, Director of Financial Aid 405-912-9000
Corrective actions were implemented for the Fall 2025 term to ensure all students are notified of Direct Loan disbursements and that sufficient documentation is maintained.
Corrective actions were implemented for the Fall 2025 term to ensure all students are notified of Direct Loan disbursements and that sufficient documentation is maintained.
Action Taken enCircle has officially adopted the policy that gift cards provided to foster parents will not be submitted for reimbursement until the receipts are returned by the parents. If they do not spend the entire amount, only the amount spent will be requested for reimbursement and enCircle wi...
Action Taken enCircle has officially adopted the policy that gift cards provided to foster parents will not be submitted for reimbursement until the receipts are returned by the parents. If they do not spend the entire amount, only the amount spent will be requested for reimbursement and enCircle will cover the difference from non-federal funds. enCircle is also considering other methods of helping parents purchase clothes for foster placements. Further, enCircle has evaluated the use of all allocation methods for expenses that impact federal grants and will be limiting allocations to only clearly explicit expenses to ensure only programmatic costs are billed. Further, enCircle has created a new service code within its Chart of Accounts to track programmatic administration costs separate from overall administration costs.
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the College re-evaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explan...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the College re-evaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Early in the 2024-25 fiscal year, the College learned that this finding related to manually reported graduates and withdrawn students. Graduates reported during the automated file submittal process were reported as graduating at end of term, while graduates reported manually were reported as graduating on the College’s actual commencement date (one day different than end of term). The Registrar is now consistent in reporting graduation dates using the end of term for all graduating students. As for the reporting of withdrawals, the Registrar now manually updates the enrollment status and effective dates in NSLDS to ensure accurate and timely reporting. The findings in this audit period occurred prior to the above changes being implemented. Name(s) of the contact person(s) responsible for corrective action: Austin Nyhof, Registrar Planned completion date for corrective action plan: June 30, 2026
FINDING #2025-001 (SF-425 Financial report – Late Submission) Responsible Party: Sara Hudson & Tonya Garber Anticipated Completion Date: November 1, 2025 (Implemented) Corrective Action Planned: Snowy Mountain Development Corporation has implemented updated procedures to ensure timely preparation, r...
FINDING #2025-001 (SF-425 Financial report – Late Submission) Responsible Party: Sara Hudson & Tonya Garber Anticipated Completion Date: November 1, 2025 (Implemented) Corrective Action Planned: Snowy Mountain Development Corporation has implemented updated procedures to ensure timely preparation, review, and submission of SF-425 Federal Financial Reports. Management reviewed current HRSA reporting requirements and established internal reporting deadlines that precede federal due dates. Reporting responsibilities and deadlines have been formally communicated to applicable staff, and management now monitors compliance with submission timelines to ensure reports are filed in accordance with federal requirements. This corrective action has been implemented for the current fiscal year ending June 30, 2026, and management anticipates compliance with SF-425 reporting requirements for future audits.
Compliance Requirement: Procurement, Suspension and Debarment Campus: Sacramento Recommendation: KPMG recommends the University implement controls to verify the suspension and debarment status of all vendors prior to entering covered transactions, as well as maintaining evidence of the suspension an...
Compliance Requirement: Procurement, Suspension and Debarment Campus: Sacramento Recommendation: KPMG recommends the University implement controls to verify the suspension and debarment status of all vendors prior to entering covered transactions, as well as maintaining evidence of the suspension and debarment check in the procurement file of each vendor. Corrective Action Plan: California State University, Sacramento The University concurs with the recommendations. The University will review and enhance its procedures and internal controls to verify the suspension and debarment status of all vendors prior to entering covered transactions, as well as maintaining evidence of the suspension and debarment check in the procurement file of each vendor. Estimated Completion Date: July 2026 Contact person: California State University, Sacramento Tabitha Leeds Senior Director of Accounting Services (916) 278-4679 leeds@csus.edu
COMPLIANCE REQUIREMENT: Disbursements to or on Behalf of Students Campus: Fullerton, Los Angeles Recommendation: KPMG recommends the University provide proper training on the disbursement notification requirements and apply its existing policies and procedures. Corrective Action Plan: California Sta...
COMPLIANCE REQUIREMENT: Disbursements to or on Behalf of Students Campus: Fullerton, Los Angeles Recommendation: KPMG recommends the University provide proper training on the disbursement notification requirements and apply its existing policies and procedures. Corrective Action Plan: California State University, Fullerton The University concurs with the recommendation. The University will review and enhance its procedures to ensure timely disbursement notification. Estimated Completion Date: March 2026 Contact person: California State University, Fullerton Nick Valdivia Director of Financial Aid nvaldivia@fullerton.edu (657) 278-3064 Justin Chan Associate Director of Accounting Services & Financial Reporting juschan@fullerton.edu (657)278-8371 Corrective Action Plan: California State University, Los Angeles The University concurs with the recommendation. The University will review and enhance its procedures to ensure timely disbursement notification. Estimated Completion Date: June 2026 Contact person: California State University, Los Angeles Linda Lopez Director, Financial Aid and Scholarships (323) 343-3247 llopez148@calstatela.edu
COMPLIANCE REQUIREMENT: Enrollment Reporting Campuses: Sacramento, Los Angeles Recommendation: KPMG recommends the University provide proper training on the enrollment reporting procedures and apply its existing policies and procedures. Corrective Action Plan: California State University, Sacramento...
COMPLIANCE REQUIREMENT: Enrollment Reporting Campuses: Sacramento, Los Angeles Recommendation: KPMG recommends the University provide proper training on the enrollment reporting procedures and apply its existing policies and procedures. Corrective Action Plan: California State University, Sacramento The University concurs with the recommendation. The University will review and enhance its procedures to ensure timely and accurate reporting to NSLDS. Completion Date: December 2025 Contact person: California State University, Sacramento Tabitha Leeds Senior Director of Accounting Services (916) 278-4679 leeds@csus.edu Corrective Action Plan: California State University, Los Angeles The University concurs with the recommendation. The University will review and enhance its procedures to ensure timely and accurate reporting to NSLDS. Estimated Completion Date: June 2026 Contact person: California State University, Los Angeles Linda Lopez Director, Financial Aid and Scholarships (323) 343-3247 llopez148@calstatela.edu
Condition The internal controls over compliance were not operating effectively as a loan was disbursed to a business which operates outside of the approved county listing set by the SBA. Corrective Action Plan Corrective Action Planned: The Foundation had 26 approved counties across the lower half o...
Condition The internal controls over compliance were not operating effectively as a loan was disbursed to a business which operates outside of the approved county listing set by the SBA. Corrective Action Plan Corrective Action Planned: The Foundation had 26 approved counties across the lower half of Michigan for businesses eligible to be funded by SBA loan capital. MWF assigned SBA funding to an applicant that was initially identified as being in an eligible county. However, by the time of the loan closing, the applicant had settled on a brick and mortar store located in a county that is not on MWF’s SBA approved list. MWF has created a procedure for loans assigned to SBA as the loan capital funding source to verify before closing that the county for the business is in an SBA approved county. The Foundation has also received approval from the SBA to fund loans for business in the previously unapproved county subsequent to year end. Name(s) of Contact Person(s) Responsible for Corrective Action: Tamara Jackson, the director of lending, will verify all loans assigned to SBA loan capital prior to closing the county of the business and confirm it is an eligible county for MWF Anticipated Completion Date: The procedure described above was created, MWF’s credit policy and MWF’s closing checklist reflect this procedure which was implemented in the first quarter of FY2026.
Criteria: In accordance with §200.303(a), Internal Controls, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulation...
Criteria: In accordance with §200.303(a), Internal Controls, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. In accordance with §200.213 and §180.300, Suspension and Debarment, nonfederal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Nonfederal entities must either check for exclusions in the System for Award Management (SAM); collect a certification from the entity, or add a clause or condition to the covered transaction with the entity prior to entering into a covered transaction with a non-federal entity. In addition, in accordance with §180.415(b), non-federal entities cannot renew or extend covered transactions (other than no-cost time extension) with any excluded person, or under which an excluded person is a principal, unless the non-federal entity obtains an exception under §180.135. Condition: During our review of procurement, suspension, and debarment compliance requirements for the selected vendor sample, we observed that while management conducted a suspension and debarment check prior to contracting with the vendor, documentary evidence of this check was not retained. Although management has maintained an ongoing working relationship with this vendor over several years and indicated that the required check was performed, they were unable to provide documentation confirming that the check was completed at the time the most recent contract was executed on April 1, 2025. Cause: The Organization’s current policies, procedures, and internal controls do not require the retention of documentation evidencing that suspension and debarment checks have been performed. Corrective Action: CCUSA Finance team will ensure that all contractors on federal grants certify that they are not suspended or debarred, and CCUSA Finance team will also verify that information on third-party and/or government websites. CCUSA will retain all documentation of the certification and verification. In addition, CCUSA will attend uniform guidance training either provided by an outside company, or by BDO. Anticipated Completion Date and Contact Details Anticipated Completion Date: March 31, 2026 Contact Person: Katie Spillane Title: Chief Financial Officer Phone Number: (703) 236 6250
Finding 2025-001 Reporting Federal Agency- U.S. Department of the Treasury Program Name - Coronavirus State and Local Fiscal Recovery Funds (SLFRF} Federal Assistance Listing Number: 21.027 2 CFR 200.303 requires that a non-federal entity must "(a) establish and maintain effective internal control o...
Finding 2025-001 Reporting Federal Agency- U.S. Department of the Treasury Program Name - Coronavirus State and Local Fiscal Recovery Funds (SLFRF} Federal Assistance Listing Number: 21.027 2 CFR 200.303 requires that a non-federal entity must "(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States and the "Internal Control Integrated Framework", issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." The terms and conditions of the funding require the recipient to submit quarterly Project and Expenditure Reports to the U.S. Department of the Treasury {Treasury). Information required to be included in these quarterly reports includes projects funded, expenditures, obligations, and other information. Treasury's Coronavirus State and Local Fiscal Recovery Guidance requires that "Reporting must be consistent with the definition of expenditures pursuant to 2 CFR 200.1." Responsible Officials: The City of Charleston utilizes an outside agency to compile and submit the required quarterly reports to the Department of Treasury for the State and Local Fiscal Recovery Funds. City officials provide the details of the projects funded, expenditures, obligations, and all other required information to the outside agency, who will then compile and submit the report. Upon review of prior period reports, City officials discovered that the expenditure amount for one of the projects was less than the amount provided to the outside agency for the report. The City brought this to the attention of the outside agency, then increased the project expenditures of the report in question so that the project to-date.
Finding Number: 2025-002 Federal Program: Student Financial Assistance (SFA) Cluster - Various ALN Control Requirement - Return of Title IV Funds Management’s Response The University of Puerto Rico concurs with this finding. Institutional units have identified opportunities for improvement in intern...
Finding Number: 2025-002 Federal Program: Student Financial Assistance (SFA) Cluster - Various ALN Control Requirement - Return of Title IV Funds Management’s Response The University of Puerto Rico concurs with this finding. Institutional units have identified opportunities for improvement in internal controls related to the timely return of Title IV funds and have implemented, or are in the process of implementing, corrective measures to ensure compliance with the regulatory timeframe of 45 days. The Cayey unit identified that the delay in the return of Title IV funds was related to an unintentional administrative error in the handling and filing of R2T4 documentation, within a context of operational transition and temporary staffing limitations. As a corrective action, the Fiscal Office will strengthen periodic reviews of total withdrawal reports generated in the NEXT system, ensure proper classification and monitoring of R2T4 cases, and provide continuous follow-up until funds are effectively returned within the 45 days regulatory timeframe. As a control mechanism, direct oversight of the R2T4 process by the Finance Director has been established, including recurring reviews of total withdrawal reports and reconciliation of these reports with refund vouchers, in order to ensure that all cases are processed and returned in a timely manner. The Humacao unit acknowledged that the cases identified by the auditors were related to specific circumstances, including system errors, technical limitations, and operational workload associated with the implementation of the shared services model. As a corrective measure, the unit implemented changes to the total withdrawal request form and process to ensure coordinated handling between the Office of Financial Aid and the Fiscal Office, allowing for early identification of cases subject to R2T4. Additionally, the Fiscal Office will review total withdrawal reports generated by the NEXT system on a recurring basis, perform R2T4 calculations timely, and coordinate with the Office of Finance to process returns within the regulatory timeframe. Oversight of the process has been strengthened through the designation of responsible personnel and continuous monitoring of active cases through completion. The Carolina unit identified that delays in the return of Title IV funds were due to discrepancies in attendance reports that were subsequently amended. As a corrective action, the Office of Financial Aid will formally notify the Fiscal Office of any corrections or amendments to attendance reports to ensure that R2T4 cases are identified timely. In addition, the use of “Never Attended” reports has been reinforced at the conclusion of the census period and upon completion of the grade submission period. Once the R2T4 calculation is completed in the COD system and a return is determined, the refund process will be initiated immediately, accompanied by continuous follow-up and the scheduling of key dates to ensure compliance with the 45 days regulatory requirement. The Central Administration Finance Office will conduct a meeting with Finance Directors, Financial Aid Directors, the Office of the Registrar, and Fiscal Directors to discuss this finding and establish a uniform procedure to address the following scenarios: • Students who request a total withdrawal. • Students who stopped attending. • Students who never attended. Additionally, a control mechanism will be implemented through the SharePoint platform, whereby each Fiscal Director will certify that system reviews have been performed for cases approaching the 45 days regulatory deadline. This control will be performed on a bi-weekly basis and will allow for timely monitoring of active cases, ensuring proper compliance with the required return of funds. For cases related to grade-based census determinations, which are processed once faculty submit grades in the system, an additional control mechanism will be established. Specifically, the SharePoint tool will be used for Fiscal Directors to document the academic calendar deadlines for grade submission. Furthermore, Fiscal Directors will schedule Outlook calendar events with these deadlines, including the Director of Financial Aid and the Office of the Registrar, and will establish automated reminders to ensure timely follow-up. These procedures will be documented and incorporated into the internal control manual applicable to the R2T4 process. Responsible Person or Office: Central Administration Finance Office and the finance offices of each of the eleven (11) institutional units. Implementation Timeline: 2026-2027
FINDING 2025-003 Finding Subject: Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lori Bennett Contact Phone Number and Email Address: 317-539-9200, LBennett@mccsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Correct...
FINDING 2025-003 Finding Subject: Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lori Bennett Contact Phone Number and Email Address: 317-539-9200, LBennett@mccsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: While the school corporation no longer has any active funds with the COVID-19 Education Stabilization Fund the school corporation will ensure that the designed or implemented a system of internal controls, which would include segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance for any future federal program. Anticipated Completion Date: January 1, 2026 INDIANA STATE
Direct Loan Disbursement Notifications Correction Action Planned: For the 2025-2026 academic year, notifications are scheduled in our FAMS system to be sent immediately after student loans are disbursed to the student account. This action started with the Fall 2025 semester. Policy and Procedures ha...
Direct Loan Disbursement Notifications Correction Action Planned: For the 2025-2026 academic year, notifications are scheduled in our FAMS system to be sent immediately after student loans are disbursed to the student account. This action started with the Fall 2025 semester. Policy and Procedures have been updated to include the Direct Loan notification statement. This is in Section 10.5, Student & Parent Notifications, on Page 48 of the Financial Aid Policies and Procedures manual. This action has already been completed and in progress as of September 2025. Person Responsible for the Corrective Action: Denise Welch, Director of Financial Aid
Noncompliance with Enrollment Status Change Reporting. Auditor Description of Condition and Effect. Of 18 enrollment status changes tested, we noted 1 change that was not reported to the National Student Loan Data System (NSLDS) within 60 days due to a student being assigned a different coding struc...
Noncompliance with Enrollment Status Change Reporting. Auditor Description of Condition and Effect. Of 18 enrollment status changes tested, we noted 1 change that was not reported to the National Student Loan Data System (NSLDS) within 60 days due to a student being assigned a different coding structure within the College's system which resulted in the student being excluded from the standard status-change reporting process. As a result of university personnel using the incorrect semester start dates. As a result of this condition, the College was temporarily out of compliance with enrollment reporting requirements. Auditor Recommendation. We recommend the College review and update its enrollment reporting processes to ensure that all students-including those with unique or foreign-student coding-are captured in routine status-change monitoring and NSLDS reporting procedures. The College should implement controls to detect nonstandard coding and ensure that all enrollment changes are identified and reported within required federal timelines. Corrective Action. Bay College took swift action after determining some students were being excluded in our enrollment reporting. Our reporting process was excluding students who were noted as being a citizen of a foreign county. We now review these students prior to each reporting cycle to determine if they should be included in the reporting. The Financial Aid team reviews this report to determine if the student is eligible for federal student aid. Students who are eligible are indicated and provided to the Institutional Effectiveness team to include in the enrollment reporting. This process is completed prior to each reporting cycle. For students who were not included in our prior reporting, the Financial Aid team working directly with the Institutional Effectiveness team, determined which should be reported and completed their enrollment reporting directly through NSLDS. Responsible Person. Ruth Carlson, Director of Financial Aid. Anticipated Completion Date. June 30, 2026
Reportable Condition: See Condition 2025-001 Recommendation We recommend the Local Area monitoring the earmarking procedures for the Youth Program on a quarterly basis to ensure that at the end of the to two years meet the requirement establish. If deviations or failure to meet the earmark are noted...
Reportable Condition: See Condition 2025-001 Recommendation We recommend the Local Area monitoring the earmarking procedures for the Youth Program on a quarterly basis to ensure that at the end of the to two years meet the requirement establish. If deviations or failure to meet the earmark are noted, communications must be generated to youth program staff to take corrective actions before the elapse of the funding period. Action Taken The Executive Director has begun meetings with staff to establish a short-term plan to discuss strategies to increase the number of youth participants in the Program. In addition, at these meetings, the Executive Director has instructed the Program Executive and Program Manager to maintain control over the budget allocated and the activities to be carried out and to coordinate the planning of future activities. With regard to the Finance Area, the Chief Financial Officer is instructed that at least every two months or at the request of the Assistance Manager submit the “Encumbrance Budget Report” to see the changes in budget and be able to make decisions related to changes in the approved budget by the Labor Department Program. In the meetings to be held, the results obtained and the status of the activities carried out in order to be accountable for the actions carried out must be reported. This to maintain continuous monitoring of the program, before the end of the validity of the funds.
R2T4 Audit: FY25 Corrective Action Plan To address the audit findings, the FCC has initiated the following actions: •Spring 2025, Completed: oRevised Processing Timeline: All R2T4 calculations and returns are now completedwithin 30 days, reserving the final 15 days exclusively for QA. (Responsible L...
R2T4 Audit: FY25 Corrective Action Plan To address the audit findings, the FCC has initiated the following actions: •Spring 2025, Completed: oRevised Processing Timeline: All R2T4 calculations and returns are now completedwithin 30 days, reserving the final 15 days exclusively for QA. (Responsible Leader:Director of Financial Aid) oCross-Training and Succession Planning:Staff cross-trained; onboarding/offboardingdutiesdocumented to eliminate single points of failure.(Responsible Leader: Director ofFinancial Aid) •September 2025, Underway: oLeadership Communication Protocol:A formal process is beingfinalized to ensurecompliance issues are documentedand escalatedforawareness to the President and theCFO/VP for Administration. Thisprotocol alsoreinforcesa cultureof accountability where compliance concernsare escalated promptly and transparently. (ResponsibleLeader: AVP for Student and Financial SupportServices) •Monthly Monitoring and Reporting:Compliance reviews reported monthlyto the VP for Student Experience and then to the President and the CFO/VPfor Administration for awareness. (Responsible Leader: VP for StudentExperience). oQA Tracking Form: Implemented to document each review and correction for auditverification. (Responsible Leader: Director of Financial Aid) •Fall 2025 – Spring 2026, To Be Planned and Executed: oExternal Program Review: FCC will engage an external consultant agency (TBD) toconduct a comprehensive Financial Aid Office program review in FY26, validatingcompliance, staffing adequacy, and process integrity. (Responsible Leader: AVP forStudent and Financial Support Services) •Timeline, Next Steps, Responsible FCC Leader: oOctober 6, 2025: Submit formal corrective action plan to Auditors (VPSE) oOctober 15, 2025: Receive first compliance review report for AVP to VP reporting toPresident’s Council, as part of enterprise risk management awareness. (AVP/VPSE) oJanuary to April 2026: Conduct external program review of the Financial Aid Office andreport findings to President and the CFO/VP for Administration by June 2026. (AVP) •Expected completion date: June 2026 •Person responsible: Dr. Edmund T. Cabellon, Interim Vice President for Student Experience
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar tha...
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar that the entire Finance staff reviews at every biweekly Finance meeting, but the WIFIA deadlines were errantly not incorporated into that tool until January 2026. While management agrees with the finding, it should be noted that management was not operating without controls. Rather, the deadline being adhered to was just the wrong date. Management submitted updated financial model/plan by January 31, 2025, which was within the month following the close of the calendar year, similarly to the quarterly construction reports that are due 30 days after the end of the preceding quarter. In addition, the data on the annual model reflected current information near the time of release of the report, not June 30, 2024. So, in substance, management provided an even more current, relevant document. Management acknowledges the additional finding language that the June 30, 2025 quarterly construction monitoring report was submitted on day 31 rather than day 30 following the close of the quarter. Finally, management acknowledges that the annual updated financial model/plan for June 30, 2025, will be submitted in January 2026 as the internal control, as mentioned above, was not corrected until January 2026, which will result in the same finding on the Single Audit for June 30, 2026. However, management believes that we have taken the appropriate measures required to avoid ongoing replication. Responsible Official: Matt Zook, Finance Director
The Organization has created a tracking system that identifies when the last inspection was completed and when the next inspection should be due based on the number of units at each complex. NOTE: Inspections are not due until June through October of 2027 for complexes under the jurisdiction of the ...
The Organization has created a tracking system that identifies when the last inspection was completed and when the next inspection should be due based on the number of units at each complex. NOTE: Inspections are not due until June through October of 2027 for complexes under the jurisdiction of the City of Salem.
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In add...
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In addition, the next step will be a BBRI for the RAD for PRAC conversion.
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In add...
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In addition, the next step will be a BBRI for the RAD for PRAC conversion.
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance – Reporting Finding 2025-010 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of...
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance – Reporting Finding 2025-010 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Per 2 CFR 200.334 the recipient must retain all federal award records for three years from the date of submission of their final financial report. Condition: During the audit we tested 9 reports and noted the following: a) There was one (1) instance out of (9) nine reports tested where the submitted reports were unable to be provided, including the date of submission for the reports. b) There were four (4) instances out of nine (9) reports tested where the County was unable to provide evidence the report was reviewed prior to submission. c) There were two (2) instances out of nine (9) reports tested where the County was unable to provide the date of submission for the reports. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: By not having the required documentation and underlying support, the County is not able to demonstrate compliance with the applicable requirements. Cause: The County did not have a formal policy to ensure documentation was retained to evidence review and submission of all reports. Recommendation: While the County made updates to policies and procedures surrounding reporting during the current year to address the prior year finding, the County should ensure these policies are adhered to ensure all submitted reports and underlying data are retained in accordance with the Uniform Grant Guidance requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: As of July 2025, The Health Department has created and adopted policy FIS-05 Retention of Reporting Requirement Submissions to ensure that federal award reports and data are retained in accordance with Uniform Guidance. The Health Department will document with screen shots as outlined in the FIS-05 Policy, to address circumstances when the required report consists of answering a NCDHHS survey or form that does not have “save” or “download” capability, to maintain record of documented submissions. In addition, the Health Department has developed a standard operating procedure whereby fiscal compliance Management Analysts, in collaboration with Program Managers, ensure they have reviewed federal award reports prior to submission and file documentation of review and approvals. While review of grant reports is common, the Health Department did not have adequate documentation to demonstrate completion of this step prior to July 2025. An additional training, to be recorded, will be held with program staff Friday December 19th, 2025. Anticipated Completion Date: December 19,, 2025 Responsible Person(s): Autumn Watson, Business Operations Director
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency and Nonmaterial Noncompliance – Child Support Non-Cooperatio...
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency and Nonmaterial Noncompliance – Child Support Non-Cooperation Finding 2025-008 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The County should have adequate documentation for each participant that supports each sanction for noncooperation. Condition: a) There was one (1) instance out of two (2) sanctions tested where the required form to be sent was dated after the sanction start date. b) There was one (1) instance out of two (2) sanctions tested where the sanction was not properly documented. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: When required sanction notifications are not issued prior to the sanction start date and sanctions are not properly documented, there is an increased risk that clients may not be properly informed of program actions and that the County may not comply with program requirements. Cause: The County did not have adequate procedures in place to ensure that required sanction notifications were issued prior to the sanction start date and that all sanctions were properly documented in accordance with program requirements. Recommendation: The County should implement procedures to ensure all required sanction notifications are issued prior to the sanction start date and that sanctions are properly documented in accordance with program requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this, which is further discussed in the Corrective Action Plan. Corrective Action Plan: Performance Improvement Strategy: Collaborate with Child Support Services to improve understanding of their processes and ensure accurate case handling. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist), Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training and Development Manager), Scott Fritz (Social Services Manager), Program Supervisors Training: Non-Cooperation Sanction Training Anticipated Completion Date: To be completed quarterly. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist). Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training and Development) Anticipated Completion Date: Completed by January 2026.
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