Corrective Action Plans

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2025-101 Lack of Effective Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization’s current review process related to the sliding fee scale t...
2025-101 Lack of Effective Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization’s current review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner does not always detect all errors. We also noted: • Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. • Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. Corrective Action Planned: The Organization has hired a new Chief Financial Officer and a new Revenue Cycle Manager. Sliding fee discount program training has been incorporated into onboarding for all new front desk employees. The billing department is adding a Patient Accounts Specialist who will monitor and review individual sliding fee determinations for accuracy and completeness and will conduct ongoing training with front desk staff as needed. Additionally, management will perform quarterly random sample testing of sliding fee determinations to verify that household size, income documentation, and discount tier were applied in accordance with the Organization's sliding fee discount policy. With respect to the school district agreement and the bus program, management will contact HRSA to request written guidance or a waiver confirming that the sliding fee discount schedule is not required to be applied to these programs. Management will also amend the Organization's sliding fee discount policies and procedures accordingly and will remove the word "disaster" from references to the bus program, as the program is not limited to disaster-related services. Person Responsible for Corrective Action: Tonya Nicholson, Chief Financial Officer Anticipated Completion Date: October 2026
Effective June 2025, the Organization hired a Director of Finance to strengthen financial management, enhance internal controls, and improve oversight of financial reporting and federal grant compliance. Management has implemented enhanced grant reconciliation procedures, documented management revie...
Effective June 2025, the Organization hired a Director of Finance to strengthen financial management, enhance internal controls, and improve oversight of financial reporting and federal grant compliance. Management has implemented enhanced grant reconciliation procedures, documented management review of reimbursement requests, and standardized reporting processes to improve the accuracy and completeness of grant reporting.
Effective June 2025, the Organization hired a Director of Finance to strengthen financial management, enhance internal controls, and improve oversight of financial reporting and federal grant compliance. The IAP program has since been discontinued. Management has implemented procedures requiring all...
Effective June 2025, the Organization hired a Director of Finance to strengthen financial management, enhance internal controls, and improve oversight of financial reporting and federal grant compliance. The IAP program has since been discontinued. Management has implemented procedures requiring all grant documentation to be maintained within centralized, Organization-controlled systems to ensure documentation is retained, accessible, and available for future audits.
Effective June 2025, the Organization hired a Director of Finance to strengthen financial management, enhance internal controls, and improve oversight of financial reporting and federal grant compliance. Management has implemented revised payroll allocation procedures, enhanced review of employee ti...
Effective June 2025, the Organization hired a Director of Finance to strengthen financial management, enhance internal controls, and improve oversight of financial reporting and federal grant compliance. Management has implemented revised payroll allocation procedures, enhanced review of employee time and effort documentation, monthly reconciliation of payroll allocations to approved timesheets before reimbursement requests are submitted, and additional management review procedures to ensure compliance with Uniform Guidance requirements.
Finding 2025-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Amber Jusefowytsch / Kim Newman / Anna Simmons Corrective Action Plan: A calendar of required reporting dates will be created with a one-month reminder to all involved parties to mitigate last minut...
Finding 2025-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Amber Jusefowytsch / Kim Newman / Anna Simmons Corrective Action Plan: A calendar of required reporting dates will be created with a one-month reminder to all involved parties to mitigate last minute issues with reporting compliance. Proposed Completion Date: This finding and corrective action plan have been reached near the end of FY26, the calendar will be implemented by December 31st, 2026 but we anticipate a similar finding for FY26.
Views of Responsible Officials: Internal review and approval of the final (close out) funding request submission was provided verbally during an in-person management retreat; both the VPFinance and the Executive Director sat side-byside during review, approval and submission process. Management ackn...
Views of Responsible Officials: Internal review and approval of the final (close out) funding request submission was provided verbally during an in-person management retreat; both the VPFinance and the Executive Director sat side-byside during review, approval and submission process. Management acknowledges the lack of written documentation and has implemented protocols to ensure all approvals are written approvals, including instances where initial approvals are verbal in nature. Management does not expect to see this finding upon completion of our FY2026 audit. Anticipated Completion Date: December 31, 2025
Finding Reference: 2025-001 Description of Finding: The Authority did not perform timely repairs on 18 units in accordance with housing quality inspection requirements. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We currently have a process t...
Finding Reference: 2025-001 Description of Finding: The Authority did not perform timely repairs on 18 units in accordance with housing quality inspection requirements. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We currently have a process to respond to all life-threatening and health and safety inspection deficiencies in a timely manner. To improve the process for all other inspection deficiencies, we are working on a way to use technology to automatically import inspection findings into our system instead of manually entering each work order. This will reduce the time it takes to create work orders, allowing repairs to be completed more quickly. The system will also provide documentation of completed repairs, helping ensure records are maintained.
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Eric L. Gurley, Executive Director Corrective Action Plan: Access Alaska has gained efficiencies and personnel through contracted relationships to use to implement timely reporting and filing requirements. Timelines...
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Eric L. Gurley, Executive Director Corrective Action Plan: Access Alaska has gained efficiencies and personnel through contracted relationships to use to implement timely reporting and filing requirements. Timelines, timetables, and responsible parties are in place to ensure completion. Proposed Completion Date: September 30, 2026.
Condition: Controls were not designed or implemented effectively to ensure: 1. Mortgage and escrow payments were made in accordance with the due dates and amounts specified in the executed mortgage note agreement. 2. Earnings are retained in the replacement reserve account 3. The Organization comple...
Condition: Controls were not designed or implemented effectively to ensure: 1. Mortgage and escrow payments were made in accordance with the due dates and amounts specified in the executed mortgage note agreement. 2. Earnings are retained in the replacement reserve account 3. The Organization completes the required financial reports in accordance with the applicable accounting basis, supported by underlying records representing the activity for the period reported. Planned Corrective Action: Management will design and implement internal controls to ensure compliance with mortgage escrow payments, reserve account funding, and quarterly financial reporting requirements, including a process to ensure that documentation of reviews is retained. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2026
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the budget submissions in question to ensure timely submission on a go-forw...
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the budget submissions in question to ensure timely submission on a go-forward basis. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2026
FINDING 2025-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Sandra L Morton Contact Phone Number and Email Address: 812-481-7000 slmorton@duboiscountyin.org Views of Responsible Officials: We disagree wi...
FINDING 2025-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Sandra L Morton Contact Phone Number and Email Address: 812-481-7000 slmorton@duboiscountyin.org Views of Responsible Officials: We disagree with the finding that the 2025 Annual P & E report current obligations were overstated by $8,300,967, which was the amount of cumulative obligations. Explanation and Reasons for Disagreement: We do not believe there was a systemic lack of effective internal controls or noncompliance throughout the audit period. We determined that the funds were fully obligated and reported the amount based on that interpretation, as was done on the previous reports submitted.
July 28, 2026 U.S. Department of Commerce 1401 Constitution Ave., NW Washington, D.C. 20230 Association of University Technology Managers, Inc. (the Association) and its affiliate AUTM Foundation, Inc. (the Foundation, and collectively, the Organization) respectfully submit the following corrective ...
July 28, 2026 U.S. Department of Commerce 1401 Constitution Ave., NW Washington, D.C. 20230 Association of University Technology Managers, Inc. (the Association) and its affiliate AUTM Foundation, Inc. (the Foundation, and collectively, the Organization) respectfully submit the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Blue & Company, LLC 250 West Main Street, Suite 2900 Lexington, Kentucky 40507 The finding from the schedule of findings and questioned costs (the Schedule) for the year ended December 31, 2025 is discussed below and is numbered consistently with the number assigned in the Schedule. Identifying Number: 2025-001 Finding: Material weakness related to consolidation of affiliate. In previous years the Association did not consolidate the assets, liabilities, net assets, revenues, and expenses of the Foundation with the financials of the Association. This was incorrect because, under Accounting Standards Codification (ASC) 958-810, the Association has a controlling financial interest in the Foundation—as its sole corporate member, with authority to appoint and remove all of the Foundation’s trustees—and an economic interest in the Foundation, so consolidation is required. The 2025 consolidated financial statements correct this, including a restatement of the beginning balance of net assets. Corrective Actions Taken or Planned: The issue occurred due to a misunderstanding of GAAP rules related to affiliated entities. Previously, management’s understanding was that common board members were the primary consideration for consolidation. The Organization has (1) consolidated the Foundation effective for the year ended December 31, 2025, with beginning net assets restated and intercompany balances eliminated; and (2) will implement a documented annual affiliated-entity assessment, performed as part of the year-end close, under which finance evaluates each related or affiliated entity against the ASC 958-810 criteria—controlling financial interest and economic interest—to determine whether consolidation is required. The assessment will be documented, reviewed and approved by the Senior Director of Finance, and reported to the Audit Committee. At this time, the Organization has no affiliated entity other than the Foundation, whose consolidation will be re-confirmed under this control each year. Estimated Completion Date: The correction is complete with the issuance of the 2025 consolidated financial statements; the recurring annual control is effective beginning with the December 31, 2026 year-end close. Responsible Personnel: Cody Embry, Senior Director of Finance, with oversight by the Audit Committee of the Board of Directors. If you have any questions or would like any additional information regarding these matters, please let us know and we will be happy to provide. Sincerely, L. Cody Embry, CPA Senior Director of Finance
Corrective action the auditee plans to take in response to the finding: Wellpinit School District acknowledges the audit finding regarding the absence of a written methodology for allocating state and local funding and staffing to the high school grade span in compliance with Title I, Part A supplem...
Corrective action the auditee plans to take in response to the finding: Wellpinit School District acknowledges the audit finding regarding the absence of a written methodology for allocating state and local funding and staffing to the high school grade span in compliance with Title I, Part A supplement not supplant requirements. At the time of the audit, the District operated under a partial exemption and believed it was appropriately following guidance from the Office of Superintendent of Public Instruction (OSPI). However, the District did not fully understand that a written methodology was still required for the non-exempt high school grade span. While allocation decisions were made using consistent practices, they were not formally documented in a manner that demonstrates compliance with federal requirements. To address this finding, the District is implementing the following corrective actions: 1. Development and Adoption of a Written Methodology The District is developing a formal, written methodology for allocating state and local funds and staffing to its high school grade span. The methodology will: • Allocate resources based on objective, neutral criteria such as student enrollment, program offerings, and staffing ratios • Ensure each high school receives the state and local resources it would otherwise receive if it were not receiving Title I, Part A funds • Clearly document that Title I status is not considered in the allocation process This methodology will be formally adopted and applied beginning with the next annual budget development cycle. 2. Strengthening Internal Controls The District is establishing internal control procedures to ensure compliance with supplement not supplant requirements, including: • Annual documentation of allocation formulas and staffing decisions • Review and approval of allocations by the Business Manager prior to budget adoption • Maintenance of supporting documentation demonstrating consistent application of the methodology 3. Training and Capacity Building District leadership and business office staff will participate in training on Title I, Part A fiscal requirements, including supplement not supplant provisions and documentation standards, utilizing guidance provided by OSPI and federal program resources. 4. Ongoing Monitoring and Oversight The Business Manager will be responsible for monitoring implementation and ensuring compliance by: • Conducting annual reviews of allocation practices • Verifying that documentation is complete and audit-ready • Updating the methodology as needed to reflect changes in enrollment, programming, or regulatory guidance 5. Implementation Timeline The written methodology and internal control procedures will be finalized prior to the development of the upcoming fiscal year budget and fully implemented for that cycle. Documentation supporting compliance will be retained annually.
Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training st...
Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2026
Identifying Number: 2025-007 Data Collection Form (DCF) Late Filing Finding: The Institute did not submit the fiscal year 2024 Data Collection Form (DCF) and related reporting package to the Federal Audit Clearinghouse within the required time frame. Corrective Actions Taken or Planned: Management a...
Identifying Number: 2025-007 Data Collection Form (DCF) Late Filing Finding: The Institute did not submit the fiscal year 2024 Data Collection Form (DCF) and related reporting package to the Federal Audit Clearinghouse within the required time frame. Corrective Actions Taken or Planned: Management agrees with the finding and has implemented, or is in the process of implementing, the following corrective actions to strengthen compliance with Uniform Guidance reporting requirements: 1. Establish Formal Single Audit Reporting Procedures • The Institute will develop and maintain written procedures governing the annual Single Audit reporting process, including the preparation, review, approval, and submission of the Data Collection Form and reporting package. Procedures will clearly identify filing deadlines, responsible personnel, required approvals, and submission requirements. 2. Assign Responsibility and Accountability • Management will formally designate responsibility for coordinating the annual audit reporting process, including monitoring auditor requests, gathering required documentation, preparing the Data Collection Form, obtaining management approvals, and ensuring timely submission to the Federal Audit Clearinghouse. 3. Implement an Audit and Compliance Calendar • The Institute will establish a compliance calendar that includes all critical audit and federal reporting deadlines. Key milestones will include audit preparation activities, auditor request completion, draft financial statement review, issuance of the auditor's reports, Data Collection Form preparation, management certification, and FAC submission deadlines. 4. Strengthen Management Review Controls • Management will implement documented review procedures for the reporting package and Data Collection Form prior to submission. Review controls will verify the accuracy, completeness, and timeliness of information reported and ensure compliance with Uniform Guidance requirements. 5. Monitor Audit Requests and Submission Readiness • A tracking mechanism will be implemented to monitor the status of auditor requests, outstanding items, and reporting package preparation throughout the audit process. Periodic status meetings will be conducted to identify potential delays and ensure timely resolution of open items. 6. Maintain Evidence of Filing and Review • The Institute will retain documentation supporting preparation, review, approval, and submission of the Data Collection Form and reporting package, including filing confirmations, management approvals, submission receipts, and related correspondence. 7. Ongoing Oversight and Compliance Monitoring • Senior management will periodically review compliance with federal reporting deadlines and monitor the effectiveness of implemented controls. Any compliance issues identified will be evaluated and addressed promptly to prevent future late filings. Responsible Officials: • Executive Vice President – Ariane Sweeney • Controller/Outsourced Accounting Partner – YPTC Associates Melissa McGuire & Samantha Glass • Director of Financial Aid – Dr. Thelbert Snowden Anticipated completion date: The Institute will implement formal reporting procedures, deadline tracking tools, management review controls, and accountability measures by December 31, 2026. These procedures will be incorporated into all future Single Audit reporting cycles.
Identifying Number: 2025-006: Special Tests—Gramm-Leach-Bliley Act Noncompliance Finding: - The Institute does not have a written information security program that addresses the seven required elements under the Gramm-Leach-Bliley Act. Corrective Actions Taken or Planned: Management agrees with the ...
Identifying Number: 2025-006: Special Tests—Gramm-Leach-Bliley Act Noncompliance Finding: - The Institute does not have a written information security program that addresses the seven required elements under the Gramm-Leach-Bliley Act. Corrective Actions Taken or Planned: Management agrees with the finding and has implemented, or is in the process of implementing, the following corrective actions to strengthen compliance with the Gramm-Leach-Bliley Act and Department of Education requirements: 1. Comprehensive Review and Revision of the Written Information Security Program (WISP) • The Institute will conduct a comprehensive review of its existing Written Information Security Program (WISP) to ensure that all required elements of the GLBA Safeguards Rule are incorporated. The revised program will be approved by senior management and maintained as a formal institutional policy. 2. Formal Risk Assessment Process • The Institute will develop and implement a documented risk assessment process to identify reasonably foreseeable internal and external risks to the security, confidentiality, and integrity of student information. Risk assessments will be performed periodically and updated as significant operational, or technology changes occur. 3. Implementation of Required Security Safeguards • Management will document and implement administrative, technical, and physical safeguards designed to mitigate identified risks and protect student information. Safeguards will be reviewed periodically to ensure continued effectiveness. 4. Ongoing Monitoring and Testing of Controls • The Institute will establish procedures for ongoing monitoring of information security controls, including periodic evaluations of the effectiveness of safeguards, review of security incidents, vulnerability assessments, and corrective action tracking. Results will be documented and retained for review. 5. Vendor and Service Provider Oversight • The Institute will strengthen oversight procedures for third-party service providers that have access to protected student information. Contracts and vendor management procedures will be reviewed to ensure appropriate security expectations and monitoring requirements are established. 6. Security Awareness Training • Annual information security and data privacy training will be provided to employees with access to student information. Training will address GLBA requirements, cybersecurity risks, data protection responsibilities, incident reporting procedures, and institutional security policies. 7. Designation of Responsible Personnel • Management will formally designate individual(s) responsible for coordinating and overseeing the Information Security Program, including risk assessment activities, monitoring efforts, policy updates, and compliance reporting. 8. Periodic Reporting to Senior Management and the Board • The Information Security Program Coordinator will provide periodic reports to senior management and the Board or appropriate governing committee regarding information security risks, monitoring activities, cybersecurity incidents, and the status of GLBA compliance efforts. 9. Annual Review of the Information Security Program • The Institute will conduct an annual review of its Information Security Program to ensure continued alignment with GLBA requirements, Department of Education guidance, emerging cybersecurity risks, and institutional operations. Identifying Number: 2025-006: Special Tests—Gramm-Leach-Bliley Act Noncompliance (Continued) Responsible Officials: • Executive Vice President – Ariane Sweeney • Chief Information Officer - Dean Lane • Controller/Outsourced Accounting Partner – YPTC Associates Melissa McGuire & Samantha Glass • Director of Financial Aid – Dr Thelbert Snowden Anticipated completion date: The revised Written Information Security Program, formal risk assessment process, monitoring procedures, and training program will be fully implemented by December 31, 2026. Ongoing monitoring, risk assessments, and annual reviews will continue thereafter.
Identifying Number: 2025-005: Special Tests—Credit Balances Noncompliance Finding: - During our testing of the Student Financial Assistance Cluster, we identified an instance in which the Institute did not refund a Title IV credit balance within the required 14-day time frame. Corrective Actions Tak...
Identifying Number: 2025-005: Special Tests—Credit Balances Noncompliance Finding: - During our testing of the Student Financial Assistance Cluster, we identified an instance in which the Institute did not refund a Title IV credit balance within the required 14-day time frame. Corrective Actions Taken or Planned: Management agrees with the finding and has implemented, or is in the process of implementing, the following corrective actions to strengthen compliance with Title IV credit balance requirements: 1. Development of Written Policies and Procedures • The Institute will develop and maintain formal written policies and procedures governing the identification, tracking, review, approval, and refunding of Title IV credit balances. Procedures will clearly define responsible personnel, required timelines, supervisory review requirements, and documentation retention standards. 2. Implementation of Credit Balance Tracking Process • Management will implement a standardized tracking process to identify Title IV credit balances immediately upon creation and monitor outstanding balances through refund issuance. The tracking log will include the student name, credit balance amount, date created, refund due date, refund date, and reviewer approval. 3. Monitoring of 14-Day Compliance Requirement • The Institute will establish controls to monitor compliance with the 14-day refund requirement, including periodic review of open credit balances and automated or manual reminders for approaching refund deadlines. Any overdue items will be escalated to management for immediate resolution. 4. Documentation of Review and Approval • Evidence of review and approval will be maintained for all Title IV credit balance refunds. Documentation will include supporting reports, refund calculations, processing dates, and supervisory approval demonstrating that refunds were processed accurately and timely. 5.Monthly Management Review • Management will perform monthly reviews of all Title IV credit balances and refund activity to verify compliance with Department of Education requirements. Review procedures will include verification that all refunds were issued within required timeframes and that supporting documentation has been retained. 7. Staff Training • Financial Aid, Student Accounts, and Finance personnel involved in processing Title IV funds will receive training on federal credit balance requirements, documentation standards, and internal control responsibilities. Training will emphasize the importance of timely refund processing and compliance monitoring. 8. Ongoing Compliance Monitoring • The Institute will periodically review credit balance activity and related controls to ensure procedures are operating effectively. Any exceptions identified will be documented, investigated, and corrected timely, with results reported to senior management. Responsible Officials: • Director of Financial Aid – Dr Thelbert Snowden • Controller/Outsourced Accounting Partner – YPTC Associates Melissa McGuire & Samantha Glass • Executive Vice President – Ariane Sweeney Anticipated completion date: The Institute will fully implement credit balance tracking procedures, documentation requirements, management review controls, and staff training by December 31, 2026. Ongoing monitoring and periodic compliance reviews will continue thereafter.
Identifying Number: 2025-004: Reconciliation Between Common Origination and Disbursement (COD) System and The Institute’s Internal Records Finding: - During our testing of the Student Financial Assistance Cluster, we noted that the Institute did not perform monthly reconciliations between its intern...
Identifying Number: 2025-004: Reconciliation Between Common Origination and Disbursement (COD) System and The Institute’s Internal Records Finding: - During our testing of the Student Financial Assistance Cluster, we noted that the Institute did not perform monthly reconciliations between its internal records and COD system data. Corrective Actions Taken or Planned: Management agrees with the finding and has implemented, or is in the process of implementing, the following corrective actions to strengthen controls over COD reporting and reconciliation activities. 1. Implementation of Monthly Reconciliation Procedures • The Institute will establish formal monthly reconciliation procedures requiring comparison of: o COD system data to internal financial aid records; o Student financial aid records to the student information system; and o COD activity to the general ledger and related financial reporting records. • The reconciliation process will be designed to verify that all aid originated, disbursed, adjusted, and reported to the Department of Education is complete and accurate. 2. Development of Written Policies and Procedures • Management will develop and maintain formal written policies and procedures governing COD reconciliation activities. These procedures will identify responsible personnel, reconciliation timelines, required documentation, review expectations, and procedures for investigating and resolving discrepancies. 3. Timely Investigation and Resolution of Differences • Any discrepancies identified during the reconciliation process will be reviewed, documented, and resolved timely. Management will maintain documentation explaining the nature of reconciling items, corrective actions taken, and the date of resolution. 4. Documentation and Retention Requirements • The Institute will maintain completed reconciliation workpapers each month, including supporting reports, reconciliations performed, explanations of variances, and documentation of corrective actions taken. Reconciliation records will be retained in accordance with federal record retention requirements. 5. Management Review and Approval • Completed reconciliations will be reviewed by supervisory personnel independent of the preparation process. Evidence of review will be documented through signed and dated approvals, electronic workflow approvals, or other documentation demonstrating that reconciliations were reviewed for completeness and accuracy. 6. Staff Training • Financial Aid and Finance personnel responsible for COD reporting and reconciliation activities will receive training regarding Department of Education requirements, reconciliation procedures, documentation standards, and internal control responsibilities. 7. Ongoing Monitoring and Compliance Oversight • Management will perform periodic monitoring of reconciliation activities to ensure procedures are operating effectively and reconciliations are completed on a timely basis. Compliance results and any significant reconciliation issues will be communicated to senior management and tracked through resolution. Identifying Number: 2025-004: Reconciliation Between Common Origination and Disbursement (COD) System and The Institute’s Internal Records (Continued) Responsible Officials: • Director of Financial Aid 0 Dr Thelbert Snowden • Controller/Outsourced Accounting Partner – YPTC Associates Melissa McGuire & Samantha Glass • Executive Vice President – Ariane Sweeney Anticipated completion date: Formal reconciliation procedures, documentation standards, and management review controls will be fully implemented by December 31, 2026. Monthly reconciliations will be performed and documented on an ongoing basis thereafter.
Identifying Number: 2025-003: Special Test-National Student Loan Data System (NSLDS) Enrollment Reporting Noncompliance. Finding - Instances of noncompliance have been identified where student enrollment changes were not reported to the NSLDS within the 60-day requirement. Corrective Actions Taken o...
Identifying Number: 2025-003: Special Test-National Student Loan Data System (NSLDS) Enrollment Reporting Noncompliance. Finding - Instances of noncompliance have been identified where student enrollment changes were not reported to the NSLDS within the 60-day requirement. Corrective Actions Taken or Planned: Management agrees with the finding and has implemented, or is in the process of implementing, the following corrective actions: 1. Development of Formal Written Procedures • The Institute will develop and maintain formal written policies and procedures governing NSLDS enrollment reporting. These procedures will clearly define reporting requirements, timelines, responsible personnel, supervisory review responsibilities, and documentation retention requirements to ensure compliance with Department of Education regulations. 2. Establishment of Reporting Calendars and Tracking Controls • Management will implement a formal reporting calendar and tracking mechanism to monitor NSLDS reporting deadlines. The tracking process will identify enrollment status changes requiring reporting and ensure all submissions occur within the required 60-day timeframe. 3. Enhanced Monitoring and Reconciliation Procedures • The Institute will perform periodic reconciliations between student enrollment records and NSLDS submissions to verify that all enrollment status changes have been reported accurately and timely. Any discrepancies identified during reconciliation will be investigated and corrected promptly. 4. Documented Review and Approval Process • Management will require documented evidence of supervisory review for each NSLDS submission. Review documentation will include dated approvals, electronic workflow approvals, or other evidence demonstrating that submissions were reviewed for completeness, accuracy, and timeliness prior to certification. 5. Staff Training and Cross-Training • Financial Aid personnel responsible for enrollment reporting will receive training on NSLDS reporting requirements and internal control procedures. Cross training will be implemented to ensure coverage during staff absences and reduce the risk of reporting delays due to personnel changes. 6. Ongoing Compliance Monitoring • Management will conduct periodic reviews of NSLDS reporting performance and maintain monitoring documentation to verify ongoing compliance with federal requirements. Any exceptions identified will be addressed through corrective action and management follow-up. 7. Oversight and Accountability • The Director of Financial Aid and senior administration will review compliance monitoring results periodically and track remediation efforts until the finding has been fully resolved. Management will maintain documentation supporting the operation of controls and timely reporting activities. Responsible Officials • Director of Financial Aid – Dr Thelbert Snowden • Executive Vice President – Ariane Sweeney • Controller/Outsourced Accounting Partner – YPTC Associates Melissa McGuire & Samantha Glass • Registrar (as applicable) – Adele Hartswick Anticipated completion date: The Institute will implement formal policies, reporting calendars, monitoring controls, reconciliation procedures, and review documentation requirements by December 31, 2026. Ongoing compliance monitoring and periodic review activities will continue thereafter.
Identifying Number: 2025-002: Documentation of Internal Controls Over Compliance Finding: We noted that controls identified by management over all material compliance requirements lack sufficient documentation to conclude application of controls is in place. Corrective Actions Taken or Planned: Mana...
Identifying Number: 2025-002: Documentation of Internal Controls Over Compliance Finding: We noted that controls identified by management over all material compliance requirements lack sufficient documentation to conclude application of controls is in place. Corrective Actions Taken or Planned: Management agrees with the finding and has implemented, or is in the process of implementing, the following corrective actions: 1. Development of Written Policies and Procedures • The Institute will perform a comprehensive review of all applicable Student Financial Assistance compliance requirements and develop formal written policies and procedures documenting the processes and controls for each material compliance area. Procedures will include the individual responsible, required documentation, review requirements, and retention standards. 2. Documentation of Internal Controls • Management will establish standardized control documentation requirements for all compliance activities. Evidence of review and approval will be maintained through signatures, initials, electronic approvals, checklists, reconciliations, or other documented support sufficient to demonstrate that controls were performed and reviewed. 3. Compliance Monitoring Checklists • The Institute will implement compliance monitoring checklists covering all direct and material compliance requirements identified in the audit, including: o Cash Management o Reporting o Student Eligibility o Student Disbursements o Credit Balance Processing o NSLDS Reporting o Gramm-Leach-Bliley Act Information Security Requirements • The checklists will be completed and reviewed periodically to provide evidence of compliance and supervisory oversight. 4. Training and Cross-Training • Financial Aid and Administrative personnel will receive training on federal student aid compliance requirements, documentation expectations, and internal control responsibilities. Cross training will be performed to mitigate risks associated with employee turnover and ensure continuity of operations. 5. Management Review and Oversight • Management will implement periodic supervisory reviews of compliance activities and supporting documentation to verify controls operating as designed. Results of compliance monitoring activities and any identified deficiencies will be reported to senior administration, and corrective actions will be tracked to completion. 6. Annual Compliance Review • The Institute will conduct an annual review of Student Financial Assistance policies, procedures, and internal controls to ensure continued compliance with Department of Education regulations, Uniform Guidance requirements, and changes in federal program requirements. Identifying Number: 2025-002: Documentation of Internal Controls Over Compliance (Continued) Responsible Officials: • Executive Vice President – Ariane Sweeney • Director of Financial Aid – Dr Thelbert Snowden • Controller/Outsourced Accounting Partner – YPTC Associates Melissa McGuire & Samantha Glass • Compliance and Information Security Personnel, as applicable Anticipated completion date: The written policies and procedures, compliance monitoring tools, and documentation standards will be fully implemented by December 31, 2026. Ongoing monitoring, training, and annual reviews will continue thereafter.
The organization will develop a procedure for the review and approval of adjusting journal entries, and attaching supporting documentation ensuring entries are being charged to the correct funding sources. Responsible Individual: Chief Financial Officer - Scott Korba Estimated Completion Date: Octob...
The organization will develop a procedure for the review and approval of adjusting journal entries, and attaching supporting documentation ensuring entries are being charged to the correct funding sources. Responsible Individual: Chief Financial Officer - Scott Korba Estimated Completion Date: October 31, 2026
2025-004 – Lack of Written Policies and Procedures Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have bee...
2025-004 – Lack of Written Policies and Procedures Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have been developed, these policies have not yet been formally approved and adopted by the Organization. As a result of this condition, the Organization did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation. We recommend that the Organization review and approve the draft policies as soon as practical, but no later than the end of fiscal year 2026. Corrective Action. The Organization has prepared a policies and procedures manual for the federal grant programs, which will be approved by the Board of Directors before the end of fiscal year 2026. Responsible Person. Rob Rafson, Executive Director Anticipated Completion Date: December 2026
2025-005 – Lack of Documentation for SAM.gov Exclusion Checks Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Organization did not retain documentation to support that the exclusion checks...
2025-005 – Lack of Documentation for SAM.gov Exclusion Checks Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Organization did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Organization verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Organization retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Organization will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Rob Rafson, Executive Director Anticipated Completion Date: December 2026
U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07HP000640-02-00 9/1/2025 – 8/31/2026 Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Complianc...
U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07HP000640-02-00 9/1/2025 – 8/31/2026 Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Compliance Criteria: Proper controls over financial reporting include the ability to prepare the schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule in accordance with requirements of the Uniform Guidance. Condition: The Organization’s internal controls over the preparation of the Schedule were not operating effectively. As a result of our audit procedures, misstatements in the Schedule were identified and adjustments to the Schedule were proposed and recorded by management. Corrective Action Plan: Management is in the process of reviewing its accounting processes and procedures over the preparation of the Schedule in order to accurately report federal expenditures incurred during the reporting period. Individual Responsible for Corrective Action: Milton Trabal, Chief Financial Officer Anticipated Completion Date: 12/31/2026
Management's Response Management will address the proposed audit adjustments effective December 31, 2024. Accounting personnel will obtain guidance from the auditor on the proper reporting of infrequent and unusual transactions as they arise. Further, management will request statements on life insur...
Management's Response Management will address the proposed audit adjustments effective December 31, 2024. Accounting personnel will obtain guidance from the auditor on the proper reporting of infrequent and unusual transactions as they arise. Further, management will request statements on life insurance contracts in order to properly monitor and record activity and investment balances. -
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