Corrective Action Plans

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Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. The University correctly determined the amount of Title IV ai...
Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. The University correctly determined the amount of Title IV aid earned for a student within the required timeframes, but due to administrative oversight, omitted one of the required awards from the return update on the student account. A regular review of R2T4 calculations will be developed to ensure that the actual returns match the return calculations. Anticipated Completion Date: August 15, 2025
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will review and revise its procedures for the frequency of ...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will review and revise its procedures for the frequency of NSLDS reporting to ensure timely reporting of enrollment changes. The University will implement a monthly enrollment audit to ensure that any change in enrollment status is identified in a timely manner and reported to NSLDS. Anticipated Completion Date: June 30, 2025
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu), University Registrar (Charee Ellison) Corrective Action: The University concurs with the finding and will monitor internal controls to ensure that the return of Title IV funds is processed in accordance with federal regulations, specifically within the required 45-day timeframe after determining a student has withdrawn from the university. The university will establish a quarterly audit and monitoring system to review all Title IV fund returns, ensuring compliance with federal guidelines. Anticipated Completion Date: June 30, 2025
The Economic Development and Housing Department will implement procedures to ensure that all annual compliance documents are collected and maintained for the life of the loan.
The Economic Development and Housing Department will implement procedures to ensure that all annual compliance documents are collected and maintained for the life of the loan.
AUDIT FINDING Finding 2024-001 Incorrect Title IV (R2T4) Calculation MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor’s finding and identification of a deficiency in our internal controls. MANAGEMENT'S CORRECTIVE ACTION PLAN We will enact stronger controls to en...
AUDIT FINDING Finding 2024-001 Incorrect Title IV (R2T4) Calculation MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the auditor’s finding and identification of a deficiency in our internal controls. MANAGEMENT'S CORRECTIVE ACTION PLAN We will enact stronger controls to ensure that all R2T4s are accurately calculated and the proper amounts are refunded in a timely manner. EMPLOYEE/ DIVISION RESPONSIBLE Financial Aid Director TIMELINE AND ESTIMATED COMPLETION DATE Immediately
Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Franklin Cummings Tech recognizes the importance of submitting the correct dates for withdrawals. These e...
Finding number: 2024-003 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Franklin Cummings Tech recognizes the importance of submitting the correct dates for withdrawals. These errors found in the audit resulted from how our previous Student Information System dated status changes. Our new Student Information System, Jenzabar, has inherent system features that will control this process more effectively. To ensure this, the Registrar will review a minimum of 50% of the withdrawals processed since the previous file submission to ensure that the date matches the withdrawal date. The Controller will also review a sample of withdrawals on the file at least once per semester to ensure this process is being followed. Timeline for Implementation of Corrective Action Plan: April 2025 Contact Person: James Klasen, Registrar
Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Given the continuing challenges of using an antiquated Student Information System to manage student withd...
Finding number: 2024-002 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063, 84.268 Award year: 2024 Corrective Action Plan: Given the continuing challenges of using an antiquated Student Information System to manage student withdrawals, FC Tech has taken the following actions as of October 1, 2024: 1. Hired a New Director of Financial Aid (September 2024) 2. Converted our Student Information System from Unit 4/CAMS to Jenzabar 3. Implemented internal procedures that include staff from Financial Aid, FA Solutions (BFCIT third-party service provider), Student Accounts & Registrar’s Office Specific Controls Implemented: 1. FA Solutions will provide a monthly report identifying students that have withdrawn from BFCIT. This report will include: a. Student Name b. Date required funds must be returned c. Status of each withdrawal: i. Completed on-time ii. In process and still within timeframe to complete the return iii. In process and at risk of not completing timely 2. The new Financial Aid Director has created, and will oversee, a Withdrawal Tracking Spreadsheet to track the progress of all Withdrawals. This spreadsheet has built-in critical dates. 3. Inherent within our new Student Information System (Jenzabar) there are built in controls that will ensure compliance and assist with the timely processing of Withdrawals and the return of Federal Funds 4. Effective October 2024 a Management Report has been created that summarizes all active withdrawals. This report will be sent to the CFO and Controller no later than 10th business day of each month. Timeline for Implementation of Corrective Action Plan: October 2024 Contact Person: Sabina Yesmin, Director of Financial Aid
Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate cost...
Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate costs in a manner that aligns with the eligibility and income requirements of the award. Using this methodology, management will identify the eligible population and appropriately incur allowable expenses associated with the award. Management will initiate a bi-weekly process to review upcoming appointments and the most recent eligibility check on recurring patients. If, during this process, a patient is identified who requires an eligibility check based on award criteria (i.e., whichever is later: four weeks or the individual's next appointment), Management team will perform re-enrollment procedures to validate that the individual is still eligible. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025
Finding 2024-003 – Fiscal Management (Material Weakness) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (53...
Finding 2024-003 – Fiscal Management (Material Weakness) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: During portions of the fiscal year, the District prepared reimbursement calculations relying on an internally developed spreadsheet tool, rather than using amounts solely obtained from the general ledger and supporting documentation. The reimbursement reports were prepared by management with limited review. Conflicts over review and other monitoring procedures occurred, and were not always resolved. Complete supporting documentation for the claimed costs were not always available. Claims and other financial reports due to ODOT were regularly submitted after the due dates. The late and/or unsubstantiated filings have resulted in lost claims for the District, and potential refunding of reimbursements received. Cause: Internal control procedures assuring timely and accurate preparation of reports and filing of the reimbursement requests were not designed or implemented adequately. Maintaining sufficient and accurate supporting documentation for each report was not possible because original data was not relied upon by management, to complete the reports and reimbursement requests. Effect or Potential Effect: The lack of effective internal control activities over cash management, including financial reporting, allowed for reporting and claims errors, from simple calculation errors to requests for reimbursements of unauthorized purposes. Improper financial reporting to the ODOT occurred regularly. Lack of timely filing of reimbursement requests for amounts claimed, resulted in lost revenues and claims that may be required to be returned. Questioned Cost: No Context: Delays in filing reimbursement claims, delays in filing financial reports to ODOT, and internal disputes regarding completion of grant reimbursement request procedures were evident. Weak or nonexistent controls over cash management, including fiscal management, may result in lost revenues and risks of creating unnecessary liabilities in the form of refunds due to ODOT.  Repeat of a Prior-Year Finding: Yes Recommendation: The District should design and implement internal control policies and procedures for cash management, including fiscal management and financial reporting. Monitoring, information and communication control activities should also be designed and implemented as part of the effort the reduce the risk of continued matters of noncompliance related to cash management. District's Response: The District acknowledges the weaknesses and its intention of correcting weaknesses. Corrective Action Plan: The District’s General Manager resigned effective September 13, 2024. The Board has adopted a plan to procure qualified professional assistance to evaluate and restructure the organization and assist in daily management activities until a new General Manager can be hired and trained. Additional assistance for resolving these deficiencies has been offered by ODOT and accepted by the Board. Planned Implementation Date: October 31, 2024 Responsible Persons: District Board, Umpqua Public Transit District
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to proces...
Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to process Medi-Cal applications. o Ongoing recruitment efforts will continue to fill vacant positions, including the hiring additional trainees to build capacity for timely eligibility determinations. • Improving Internal Processes: o The County is conducting a review of workflows to identify inefficiencies and implement streamlined processes that eliminate bottlenecks. o Digital tools and automation are being introduced to enhance efficiency and accuracy case processing. • Providing Additional Support: o Overtime opportunities are being offered to eligibility specialists to expedite the processing of pending cases. o Applications are being assigned to Eligibility Specialists on a weekly basis to ensure consistent progress in reducing the backlog. • Enhancing Monitoring and Reporting: o Administrative staff are generating weekly reports from CalSAWS to track the status Medi-Cal pending applications and monitor progress. o Weekly meetings are being held with supervisors to review performance, discuss challenges, and adjust strategies as needed. • Strengthening Internal Controls: o The County is improving its internal controls to prevent future delays, including increased use of system reports to identify applications nearing the 45-day processing requirement, regular audits of the eligibility determination process and enhanced compliance training for staff. • Ongoing Evaluation and Adaptation: o Progress will be assessed weekly to ensure the implemented measures are effective. Adjustments will be made as needed to maintain compliance with the 45-day requirement. Proposed Completion Date: The county has already implemented this process and expects it to be completed by July 31, 2026.
Earmarking Earmarking requirement was not met. Corrective Action Plan: State Procurement rules occasionally make it difficult to spend the earmark by the deadline. In the future, the committee that governs these earmarks will be more proactive about monitoring planned procurements to ensure they are...
Earmarking Earmarking requirement was not met. Corrective Action Plan: State Procurement rules occasionally make it difficult to spend the earmark by the deadline. In the future, the committee that governs these earmarks will be more proactive about monitoring planned procurements to ensure they are moving through the process so funds can be spent. In addition, vacancies contributed to falling short of the earmarking requirement, since those personnel funds were not spent. Vacancies will be monitored quarterly for re-allocation opportunities, and workforce development strategies will be developed and implemented to address shortages. Implementation Date: July 1, 2025 Responding Official: Keli, Acquaro, Administrator, Child & Adolescent Mental Health Division
Finding 547917 (2024-003)
Significant Deficiency 2024
2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set f...
2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR Section 685.309(b)(2), the College is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The College does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Context: From a population of 26 students that withdrew officially and unofficially during a term, we tested 3 students and noted those students’ withdrawals were not reported timely or accurately. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Recommendation: We recommend that a review process be put in place to ensure timely and accurate enrollment reporting to NSLDS and additional training on the reporting requirements as needed. Management Response: Management is working with the Registrar’s Office to determine why there was an issue and provide a process that will eliminate any untimely reporting to Clearinghouse moving forward. If the Federal Audit Clearinghouse has questions regarding this plan, please call Angie Edmondson, CFO, 276-944-6755, aedmonds@emoryhenry.edu
Finding 547915 (2024-004)
Significant Deficiency 2024
2024-004 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Return of Title IV Refunds (Significant Deficiency) Condition: Title IV refunds for the two students tested were calculated incorrectly. Criteria: When the recipient of Title IV grant or loan assistance withdraws fr...
2024-004 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Return of Title IV Refunds (Significant Deficiency) Condition: Title IV refunds for the two students tested were calculated incorrectly. Criteria: When the recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of Title IV grant or loan assistance that the student earned as of the student’s withdrawal date in accordance with 34 CFR 668.22. The institution must return the lesser of the total amount of unearned Title IV assistance or an amount equal to the total institutional charges incurred by the student for the payment period or period of enrollment multiplied by the percentage of Title IV grant or loan assistance that has not been earned by the student. Cause: Controls are not functioning properly. Effect: The amount returned was incorrect for the two students that required refund calculations. Context: From a population of 60 students that official or unofficially withdrew from a payment period, we tested nine and noted that two students required refund calculations. Repeat Finding from a Prior Year: No Recommendation: We recommend the College put procedures in place for accurate preparation and calculation of Title IV refunds. Management Response: We agree the institution must return the lesser of the total amount of unearned Title IV assistance or an amount equal to the total institutional charges incurred by the student for the payment period or period of enrollment multiplied by the percentage of Title IV grant or loan assistance that has not been earned by the student. This issue arose from a lack of leadership and staff training in the Financial Aid Office over the past several years. As a result, proper procedures for calculating and returning unearned Title IV assistance were not consistently. Currently, staff are undergoing comprehensive training in all areas of Title IV and Higher Education Act (HEA) regulations. In the 2024-2025 academic year, the institution hired a new director of financial aid, who has implemented a system to process withdrawals online through Common Origination and Disbursement (COD) and has been working to maintain necessary documentation for accurate refund calculations. Additionally, an updated policies and procedures manual is being finalized to ensure that all staff members have access to the necessary resources and guidelines for compliance. If the Federal Audit Clearinghouse has questions regarding this plan, please call Danielle Pfaff, Controller at 1-336-316-2140 or dpfaff@guilford.edu.
Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting d...
Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting delays or errors, whether due to system malfunctions, manual processing errors, or lack of oversight Corrective Actions • Submit corrected enrollment data to NSLDS for all affected students using our National Student Clearinghouse. • Ensure that all errors identified during the audit are addressed, and follow up to confirm the corrections are reflected in NSLDS. • Notify any impacted students of any changes in their enrollment status and provide necessary support if their loan repayment terms are affected. Process and Policy Improvements • Develop and implement clear policies to ensure accurate and timely submission of enrollment data within the required 30-day reporting window or in accordance with scheduled reporting intervals. • Automate the enrollment reporting process where possible to minimize manual data entry errors. • Establish cross-departmental communication protocols to ensure timely updates on student withdrawals, graduations, and status changes. • Create detailed documentation of reporting procedures for staff training and compliance purposes. Monitoring and Compliance • Implement regular reconciliation checks between our student information system (SIS) and NSLDS to ensure data accuracy • Conduct periodic internal audits to identify discrepancies before external audits occur • Designate staff to oversee enrollment reporting and ensure adherence to federal regulations. Staff Training • Provide comprehensive training for staff responsible for enrollment reporting on NSLDS requirements, deadlines, and best practices • Offer training sessions as regulations change or system updates occur. Reporting and Documentation • Maintain records of all corrected data submissions, audit results, and communications with NSLDS • Document procedural changes and staff training efforts Responsible Person for Correction Action Plan: Dianna Ruyle, Director of Records, Registration and Advising Implementation Date for Corrective Action Plan: Immediately and ongoing
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written proc...
Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written procedures for verifying loan amounts prior to disbursement • Implement a two-step verification process for loan packaging System Controls • Collaborate with IT to implement automated system checks to flag discrepancies • Enhance reporting tools for regular audits and monitoring Staff Training • Conduct comprehensive training sessions for financial aid staff on federal regulations regarding Direct Loans • Provide ongoing refresher courses and updates as federal policies change Monitoring Continuous Improvement • Establish a quarterly audit process to ensure compliance • Monitor loan discrepancies detected and correct as needed • Conduct regular audits to confirm compliance with federal loan regulations. • Collect feedback from staff on the effectiveness of training Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/03/25
Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and r...
Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and return any excess funds to the Department of Education. (Completed) • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies • If the excess aid cannot be adjusted within the same academic year, follow federal guidelines to return any over awarded federal funds through the Common Origination and Disbursement (COD) system • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed System Enhancements • Implement system-level edits and warnings in the financial aid software to flag over-awards before disbursement. • Schedule regular audits of loan disbursements to ensure ongoing compliance Policy and Procedure Update • Update the financial aid packaging policy to include stricter controls for verifying subsidized need calculations. • Implement a cross-check system for all financial aid components before loan disbursement • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct training sessions for financial aid staff on loan eligibility calculations. • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent over awards • Provide guidance on using the financial aid management system's tools to avoid over-awards Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 02/25/25
View Audit 351835 Questioned Costs: $1
2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance an...
2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the 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. 2 CFR Section 200.430, Compensation – Personal Services, states that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable and properly allocated. Condition: During our testing of the Sheriff Department’s compliance with allowable costs/cost principles requirements, we noted that thirty-three (33) of forty (40) overtime cost calculations were miscalculated. Cause: Equitable sharing funds may not be used for salaries, except under certain provisions outlined in Section V.B.3 of the Equitable Sharing Guide including overtime. The Sheriff’s Department calculates the allowable portion of personnel salaries using a separate template that contained a formula error which inaccurately calculated the total salaries costs allocated to the program. The Sheriff’s department did not have internal controls in place to ensure that the allowed salaries were being calculated correctly. However, the error was detected after the 5th out of 6 months in which these types of costs were allocated to the program. Effect: Salary costs were allocated to the program in an incorrect amount. Questioned Costs: Our testing resulted in questioned costs in the amount of $3,550. However, the total questioned costs for the total population was $23,409. Context/Sampling: A sample of forty (40) individuals were selected from a population consisting of (840) payroll transactions. Repeat Finding from Prior Years: No. Recommendation: We recommend the Sheriff’s Department establish and maintain internal controls to ensure the overtime calculations are being accurately allocated to the program. Management Response and Corrective Action: 1. Person Responsible: Tiffany Mui, Fiscal Administrator 2. Corrective Action Plan: a. Staff corrected the formula error in the Overtime (OT) calculation workpapers. Detailed workpapers, including formulas, will be reviewed by Fiscal Administrator. b. Updated desk procedures for Sheriff’s Narcotics task will include updated OT calculation change. Procedures will be reviewed and initialed by Fiscal Administrator and Sr. Fiscal Manager. 3. Anticipated Implementation date: March 2025
View Audit 351824 Questioned Costs: $1
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance ...
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the 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. Condition: For two (2) out of three (3) project application summary reports tested, the OCPW did not retain evidence to document the individual who reviewed and approved the required reports. Cause: The department’s procedures did not include documenting the review and approval of the reports prior to submission. Effect: Ineffective controls over this area of compliance could result in reports that are inaccurate or incomplete being submitted or disclosed to the granting agency. Questioned Costs: No questioned costs were identified as a result of our audit procedures. Context/Sampling: A non-statistical sample of three (3) of nine (9) Grant Project Application Summary Reports were selecting for testing. The condition above was identified during our procedures over reporting testing. Repeat Finding: No. Recommendation: We recommend the OCPW department revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. Management Response and Corrective Action: 1. Person Responsible: • FEMA Public Assistance Grants Coordinator – Responsible for completing reports, uploading documents to the FEMA Grants Portal, and ensuring accurate records. • OCPW Emergency Manager Responsible for reviewing, approving, and submitting project applications. 2. Corrective Action Plan: • Revised Procedures for Review and Approval: i. The FEMA Public Assistance Grants Coordinator will be responsible for completing the Project Application Summary Reports. ii. Upon completion, the Grants Coordinator will upload all supporting documents into the FEMA Grants Portal. The system automatically timestamps each document and records the name of the individual who uploaded it, ensuring clear documentation of the review process. iii. After all required documents are uploaded, the OCPW Emergency Manager will be notified that the project application is ready for review. iv. The OCPW Emergency Manager will then: 1. Review the submitted documents in the FEMA Grants Portal. 2. Confirm that the reported costs align with the information provided by the reporting County agency. 3. Approve and submit the project application to Cal OES and FEMA for project approval. • Retention of Documentation: i. The FEMA Grants Portal serves as the official system of record, ensuring all uploaded documents are timestamped and traceable. ii. All project application approvals, cost documentation, and required forms will be retained electronically within the system for audit and compliance purposes. • Training and Implementation: i. Staff responsible for grant reporting will receive training on the revised process, including proper document upload procedures and compliance expectations. ii. The updated process will be implemented immediately. • Monitoring and Compliance: i. The OCPW Emergency Manager will conduct semiannual internal reviews of project applications to ensure compliance with the updated procedures. ii. Any issues identified during internal reviews will be addressed through additional staff training and process improvements. 3. Anticipated Implementation date: Immediate, March 18, 2025 • Staff Training: Within 30 days • Semiannual Compliance Review: Beginning next quarter i. First review will take place May 1, 2025. Followed by another review in October 2025.
2024-014 Program: Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.566 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Activities Allowed or Unallowed, Al...
2024-014 Program: Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.566 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Eligibility Type of Finding: Material Deficiency in Internal Control Over Compliance and Material Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the 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 Title 45 Subtitle B Chapter IV Part 400 Subpart E Section 400.53, General Eligibility Requirement, states that eligibility for refugee cash assistance is limited to those who: (1) Are new arrivals who have resided in the U.S. less than the RCA eligibility period determined by the Office of Refugee Resettlement (ORR) Director in accordance with Section 400.211; (2) Are ineligible for TANF, SSI, OAA, AB, APTDD, and AABD programs; (3) Meet immigration status and identification requirements in Subpart D (Immigration Status and Identification of Refugees); (4) Are not full-time students in institutions of higher education, as defined by the ORR. Per Title 45 Subtitle B Chapter IV Part 400 Subpart E Section 400.66, Eligibility and payment levels in a publicly-administered RCA program, states that in administering a publicly-administered refugee cash assistance program, the agency must operate its refugee cash assistance program consistent with the provisions of its TANF program including the determination of initial and on-going eligibility. Condition: During our testing of the SSA’s compliance with eligibility and allowable cost/cost principles, we noted the following: For two (2) out of forty (40) cases selected for testing, the participants’ country of origin did not meet the general eligibility requirements of the program. For two (2) out of forty (40) cases selected for testing, participants received cash assistance outside of the eligibility period. For six (6) out of forty (40) cases selected for testing, the SSA did not retain the required documentation to evidence eligibility under the program. Cause: The SSA did not follow their policies to verify and withhold the information described in the condition and did not consistently ensure that participants were eligible. Effect: Benefits were provided to ineligible participants. Questioned Costs: Questioned costs for cases tested in which we determined to be ineligible to receive cash assistance or cases in which there was insufficient documentation to substantiate the eligibility determination was $7,578. Context/Sampling: A nonstatistical sample of forty (40) out of all active program participants were sampled. For ineligible or unsupported cases we have projected the amount of questioned costs against the remining population for a total of $460,581. The condition above was identified during our procedures over eligibility, activities allowed or unallowed, and allowable costs/cost principles testing. Repeat Finding: No Recommendation: We recommend that the SSA department strengthen its internal controls to ensure that program eligibility criteria are properly supported and retained in case files. Management Response and Corrective Action: 1. Person Responsible: Rosa Palacios, Human Services Manager 2. Corrective Action Plan: SSA will implement the following to enhance internal controls over compliance with eligibility: • Policy and Procedure Review & Update: Review and update existing policies and procedures to ensure clarity of eligibility criteria, including country of origin, eligibility period, and documentation retention requirements. These actions will provide clearer guidelines to prevent future eligibility issues and ensure proper documentation retention. Complete by April 2025. • Ongoing Monitoring & Compliance Review: Establish a dedicated team to perform monthly reviews of all approved cases, ensuring compliance with eligibility requirements. A monthly report will detail trends, non-compliance issues, and corrective actions results. With these actions, we will have continuous oversight and prompt corrective actions to maintain program integrity. Implement reviews by May 2025. • Mandatory Eligibility Checklist: Implement a mandatory eligibility checklist for all staff to confirm the required eligibility documents, system entries, and action notices at initial application and semi-annual reporting. These actions ensure staff consistently follow eligibility requirements and semi-annual reporting processes. Implement by May 2025. 3. Anticipated Implementation date: April 2025 and May 2025
View Audit 351824 Questioned Costs: $1
Contact person(s) responsible for corrective action – Lisa Lawson, Sr. Accountant Corrective action planned – KMHS will move forward with billing benefit expenses as actual as of January 2025 contract billing. All employee and employer benefit costs will be billed out per the actual benefits enroll...
Contact person(s) responsible for corrective action – Lisa Lawson, Sr. Accountant Corrective action planned – KMHS will move forward with billing benefit expenses as actual as of January 2025 contract billing. All employee and employer benefit costs will be billed out per the actual benefits enrolled and received. Anticipated completion date – 1/31/2025
Finding 547610 (2024-002)
Significant Deficiency 2024
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the req...
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the required 60 days. We also identified 3 students from our sample of 25 whose withdrawal date was reported as the day after the withdrawal began and 1 student whose withdrawal date was reported as the end of the semester in which the student was attending. We also identified 2 students from our sample of 25 who were reported as withdrawn instead of graduated. Corrective Action Taken or Planned: Actions Taken The University has already taken corrective action on this finding. The issues raised were addressed in the following ways: number of days between the enrollment change and reporting was not within the required 60 days Graduate File Corrections: We discovered (Fall 2023) an error in the reporting of graduates, despite timely reporting via Degree Verify. Upon this discovery, we met with the National Student Clearinghouse (NSC) to determine the cause of the issue and how to correct it. We learned that students with enrollment in more than one program, or where the program reported did not match the program on record with NSC, were not being properly processed with a G status via the Degree Verify submissions. We were informed that this is common for institutions where students may be enrolled in more than one program at a time. We were advised by NSC to submit a “Graduates only” file, in addition to the Degree Verify file submission. Upon discovering this, we submitted Graduates only files for branches 02, 03, 04, 05, 80, 82, 84, and 97, for all terms for 2020, 2021, 2022, and 2023 beginning in December 2023 and ending in April 2024. We worked through these submissions with NSC, and incorrect withdrawn statuses were corrected to graduated statuses. Antioch’s enrollment reporting process has been updated to include a monthly submission of a graduates only file in addition to degree verify file monthly submission. The University has experienced changes in staffing for personnel involved in enrollment reporting. The person previously in charge of Enrollment Reporting retired on 02/29/24. He was responsible for the enrollment reporting for the majority of this audit period, as well as the prior year. Antioch University hired a new Director of Records Administration with a primary responsibility for NSLDS reporting on 03/28/24. The University has implemented a comprehensive training plan, including improved documentation of procedures, increased clarity regarding the process for the necessity of error resolution, and a review of system processing to help reduce errors in reporting and increase efficiency. The review of current practice and improved procedures was in conjunction with consultants from AACRAO, NSC, Ellucian (the student information system company). Actions Planned The University plans for corrective action on this finding. This includes policy updates for withdrawal processing and implementation of internal audits. Withdraw date was reported as the day after the withdraw began. It has been the practice to process withdrawal requests in this way: When a student withdrawal is submitted, the notification date is considered the last date of active enrollment. The withdraw (W) status begins effective on the following date. This has not been raised as a finding in prior audits. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c). For withdrawal processing effective immediately, this process will be updated to start the withdrawal on the date the student provides official notification, rather than starting on the day following. This means the last date attended and the start of the withdrawal will be the same date. Per the CFR 668.22(c). the student's withdrawal date is—(ii) The date, as determined by the institution, that the student otherwise provided official notification to the institution, in writing or orally, of his or her intent to withdraw; For withdrawal processing effective at the end of the term, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. Per the Withdrawal versus Graduation and Effective Dates section of the NSLDS Manual Nov 2022, p.23 - In the case of the student who completes a term and does not return for the next term, leaving the course of study uncompleted, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Withdraw date was reported as the end of the semester in which the student was attending It has been the practice to process withdrawal requests in this way: When a student requests withdrawal but has completed courses, the grades are updated prior to processing the withdrawal request. The withdrawal is effective on the start date of the next term. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c) and the NSLDS Manual as outlined in the prior bullet point. For students withdrawing immediately from a term in which they’ve already completed one or more courses, the effective date for the ‘W’ status is the date AU is notified. However, they will only be dropped from courses still in progress. Completed courses cannot be withdrawn. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Reported as withdrawn instead of graduated The Grads Only submission did not return student records for 24SPTRI. We will need to review this with Ellucian to determine the issue. Once this is determined, we will re-run the submission for this term to update records. An internal audit process will be implemented to spot check 3-5 records on each submission for enrollment, grads only, or degree verify reporting. In addition, an audit report will be created to review 9 sample records on a quarterly basis from the current list of active students and the last two years of graduated and withdrawn students. The review will select 3 records from each status. An audit log will document these reviews. Person Responsible for Corrective Action: The Registrar and Executive Director of Financial Aid & Scholarships are responsible for executing the corrective action plan. The Executive Director of Financial Aid and Scholarships and the University Registrar will meet on a recurring basis to jointly review enrollment reporting procedures and National Student Loan Data System (NSLDS) reporting timelines. This collaboration ensures that all enrollment data submitted for Title IV purposes is accurate, timely, and aligned with institutional policies and federal regulations. Any discrepancies or issues identified are addressed collaboratively and corrective steps are documented. Anticipated Completion Date: Fiscal year 2025
Finding 547609 (2024-001)
Significant Deficiency 2024
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The U...
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The University did not fully comply with FSA Handbook and federal regulations for returning Title IV aid in a timely manner. Corrective Actions Underway 1. Enhanced Quality Assurance Measures Implementation of a new review protocol for Title IV refund calculations, including a secondary verification process before fund returns. Establishment of a biweekly internal audit of refund calculations to identify and resolve errors before submission. 2.Ongoing Compliance Monitoring and Prevention Efforts Establishment of a quarterly compliance review conducted by the Financial Aid leadership team to proactively address potential issues. Development of a standardized documentation process for all Title IV transactions and NSLDS updates to ensure clear audit trails. Creation of staff retraining initiative to reinforce compliance expectations and best practices. Next Steps: Conduct a full compliance assessment at 30, 60, and 90 days to confirm improvement and adjust protocols as needed. Establish a reporting dashboard for real-time tracking of Title IV refunds and enrollment status updates. Formalize a policy review cycle to ensure that all processes remain aligned with the latest federal regulations. These actions are intended to strengthen the University’s compliance posture, mitigate risks, and enhance the accuracy and timeliness of financial aid administration. Please let me know if additional measures or oversight mechanisms should be considered. Person Responsible for Corrective Action:The Executive Director of Financial Aid & Scholarships is responsible for executing the corrective action plan. Anticipated Completion Date: Fiscal year 2025
Corrective Action Plan: The College agrees with this finding. After disbursing aid for the first time in the Fall 2023 semester and sending Pell origination and disbursement records to COD, the College ran the Pell COD Reject Report (PCRR) in Colleague to identify records that COD had rejected. CO...
Corrective Action Plan: The College agrees with this finding. After disbursing aid for the first time in the Fall 2023 semester and sending Pell origination and disbursement records to COD, the College ran the Pell COD Reject Report (PCRR) in Colleague to identify records that COD had rejected. COD identified 8 students whose Pell disbursement was rejected due to citizenship status issues. These files were reviewed and it was identified that a required field in Colleague was not populated correctly to indicate to COD that the citizenship issue had been reviewed by collecting the required documentation from the student. The files were being reviewed and updates were made in Colleague but not within the 15-day window. Procedure notes have been updated and training has occurred to ensure all relevant personnel understand the process and know where to make the appropriate updates in Colleague when reviewing citizenship documents. Status of Correction Action: Completed
The College agrees with this finding. The Registrar’s Office will proactively report withdrawals from the College between academic semesters manually to the National Student Clearinghouse (NSC) in a timely manner to ensure that NSLDS receives those status changes within the required 60-day window. ...
The College agrees with this finding. The Registrar’s Office will proactively report withdrawals from the College between academic semesters manually to the National Student Clearinghouse (NSC) in a timely manner to ensure that NSLDS receives those status changes within the required 60-day window. The Registrar will work with IT to create a report to assist in identifying all withdrawals that are processed between terms. Staff will use this report to crosscheck status changes reported to the NSC. The Registrar’s Office will follow up with the Audit Support division of the NSC regarding previous guidance on effective dating of withdrawals. The NSC’s directive to use the day after the final date of a completed term seems to contradict the effective date that the Clearinghouse automatically assigns when a student is not reported for the subsequent term.
Finding 547585 (2024-007)
Significant Deficiency 2024
USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will work with our area USDA office to evaluate the amounts required to be in the USDA Community Facilities Loan Reserve Accounts. Once we mutually agree on the required amounts, we will bring the amount in the reserve acc...
USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will work with our area USDA office to evaluate the amounts required to be in the USDA Community Facilities Loan Reserve Accounts. Once we mutually agree on the required amounts, we will bring the amount in the reserve accounts to the required balances. Person Responsible for Corrective Action Plan: Joe Botana - Interim CFO Anticipated Date of Completion: June 30, 2025
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