Corrective Action Plans

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Although there was a procedure in place for timely reporting of withdrawals, an employee retirement caused the lapse in reporting. As a safeguard in the future, we have updated the documents procedures to indicate that all documents will be sent digitally to the registrar’s office, rather than a com...
Although there was a procedure in place for timely reporting of withdrawals, an employee retirement caused the lapse in reporting. As a safeguard in the future, we have updated the documents procedures to indicate that all documents will be sent digitally to the registrar’s office, rather than a combination of paper delivery and/or email. By only email delivery, a trail can be followed to ensure both offices have received notification that the withdrawal process and its completion. As an additional safeguard, a regular review between all offices that manage student withdrawals will be conducted to ensure student cases have been completed timely. The email communication plan was put into place on February 13th, the monthly review will begin with the Month of March 2025.
Finding 561094 (2024-003)
Significant Deficiency 2024
Finding 2024-003 Condition: The County incorrectly reported expenditures on their annual Project and Expenditure (P&E) report for the fiscal year ended November 30, 2024. There were excluded expenditures for one project and overstated expenditures for various projects related to prior year exclusi...
Finding 2024-003 Condition: The County incorrectly reported expenditures on their annual Project and Expenditure (P&E) report for the fiscal year ended November 30, 2024. There were excluded expenditures for one project and overstated expenditures for various projects related to prior year exclusions, which are now reported correctly in total. Plan: The County should ensure all expenditures incurred within the fiscal year are included on the annual report. Name of Contact Person: Nikki Lohman, Treasurer Management Response: The County will work closer with Bellwether to ensure the expenditures are matching and included in the report. Anticipated Date of Completion: November 2025, anticipated date of ARPA funds being fully expensed.
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Fina...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) 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 – 6/2025 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Due to non-compliance with timely and accurate student enrollment change submissions to the National Student Loan Data System (NSLDS), Brigham Young University – Hawaii (BYUH) Management proposes the following corrective action plan to mitigate reporting errors. The Registrar’s Office, in coordination with BYUH’s Enterprise Information Systems team, will review and enhance the processes used to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse (NSC) and NSLDS. This includes: -Reviewing all relevant PeopleSoft updates and ensuring that corresponding changes are reflected in the data transmitted to NSLDS. -Testing and validating the reporting processes within PeopleSoft to confirm data accuracy and completeness. -Verifying that the correct data is being transmitted to NSLDS. -Testing the student data within NSLDS to ensure its integrity. -Documenting the entire process for future reference and ongoing quality assurance. In addition, the Registrar’s office has already added additional resources to run all reporting processes. The Registrar’s office has also reached out to Ensign College to learn about their reporting process. The University is considering contacting the PeopleSoft reporting specialist that Ensign used, although that decision will be made at a later date, and if necessary. These actions will enable the Registrar’s Office to more effectively review credit load determinations and accurately establish program begin dates for students. Daryl Whitford, Registrar, will remain responsible for enrollment reporting at BYUH. She will oversee the implementation of the revised process, provide training to all relevant staff members, and lead the development and implementation of a control mechanism to ensurefuture compliance with NSLDS reporting requirements within PeopleSoft. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that all items noted in the corrective action plan will be implemented by September 1, 2025. Signed and Acknowledged Daryl Whitford, BYUH Registrar
Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Upon the discovery of the underfunding of the debt service reserve account, the Facility discussed the situation with the Facility’s USDA contact. ...
Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Upon the discovery of the underfunding of the debt service reserve account, the Facility discussed the situation with the Facility’s USDA contact. The USDA has approved an action plan for the Facility to replenish the debt service reserve account by February 2028 with $5,000 monthly deposits which began in December 2024. Responsible Party: Mariah Voeltz, Acting Administrator Estimated completion date: December 31, 2024
2024-004 – Material Weakness – Noncompliance in Reporting Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Management will put processes into place to ensure an auditor is engaged to complete a s...
2024-004 – Material Weakness – Noncompliance in Reporting Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Management will put processes into place to ensure an auditor is engaged to complete a single audit in accordance with the Uniform Guidance to complete timely submission to the Federal Audit Clearinghouse of the audit report and data collection form. Responsible Party: Mariah Voeltz, Acting Administrator Estimated completion date: June 30, 2025
FINDINGS—FEDERAL AND STATE AWARDS 2024-001 Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: Auditors recommend the Commission review and update procurement policies to include suspension and debarment to ensure it meets the minimum requirements of 2 CFR 200 for all ...
FINDINGS—FEDERAL AND STATE AWARDS 2024-001 Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: Auditors recommend the Commission review and update procurement policies to include suspension and debarment to ensure it meets the minimum requirements of 2 CFR 200 for all federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Verify on sam.gov for all vendors we purchase any equipment or software from during the year. Also every January verify all vendors we work with are still okay on sam.gov Name(s) of the contact person(s) responsible for corrective action: Sara Otting, Controller Planned completion date for corrective action plan: February 28, 2025
Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-002 – Non-Compliance with Financial Need Requirements for Subsidized Direct Loans Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268 Award T...
Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-002 – Non-Compliance with Financial Need Requirements for Subsidized Direct Loans Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268 Award Titles: Federal Direct Student Loan Program Award Years: 7/2023 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan The incomplete installation of a student information system (PeopleSoft) update resulted in certain EFCs not prorating correctly. The incomplete system update that created this issue has been corrected. Moving forward, all PeopleSoft updates will be reviewed upon completion by Jesus Garcia, PeopleSoft project manager, to ensure all steps have been finalized as expected. Additionally, with the implementation of the 2024–25 FAFSA Simplification Act, prorated EFCs are no longer applicable. As such, this issue will not recur in future processing cycles. Timing The incomplete PeopleSoft update was corrected in March 2024. PeopleSoft updates are done every quarter and will be reviewed upon completion by Jesus Garcia. Because the 2024-25 FAFSA Simplification Act eliminated the use of prorated EFCs in this process there will be no further action taken. Sincerely, S. Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109
View Audit 356621 Questioned Costs: $1
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.
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