Corrective Action Plans

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The Office of Student Financial Services acknowledges the finding related to the Return of Title IV Funds. We recognize the importance of ensuring accurate calculations and timely return of unearned Title IV funds as part of our federal compliance obligations. The Office of Student Financial Service...
The Office of Student Financial Services acknowledges the finding related to the Return of Title IV Funds. We recognize the importance of ensuring accurate calculations and timely return of unearned Title IV funds as part of our federal compliance obligations. The Office of Student Financial Services will strengthen procedures for Return of Title IV (R2T4) calculations. All withdrawals will be reviewed using the R2T4 calculation worksheet, and calculations will be verified by a second staff member prior to posting. A tracking log will be maintained to ensure funds are returned within required timeframes. Written procedures will be updated to include required timelines and review steps. Staff training will be conducted to ensure consistent application of federal regulations. The Director of Financial Aid will periodically review completed calculations for accuracy. These actions are intended to correct the issues that contributed to the calculation errors and delays noted during the audit and to ensure compliance with Return of Title IV Funds regulations moving forward.
The University concurs with the finding that the University does not have a written information security program that addresses all required elements of the Gramm-Leach-Bliley Act . While the University processes defined to address GLBA are in place, the Information Security Policy does not specific...
The University concurs with the finding that the University does not have a written information security program that addresses all required elements of the Gramm-Leach-Bliley Act . While the University processes defined to address GLBA are in place, the Information Security Policy does not specifically address Gramm-Leach-Bliley Act (GLBA) security criteria. It is now understood that the defined processes that address and support GLBA security criteria need to be put into a format that is published for access by the Lincoln community. Lincoln has started the process to create and publish the written information security program that addresses all required elements of GLBA. The corrective measures above are designed to ensure full compliance with all required elements of the GLBA.
The Office of Student Financial Services acknowledges the findings related to Reporting: Financial Reporting through the Common Origination and Disbursement (COD) System. We recognize the importance of accurate and timely reporting of origination data to ensure compliance with federal Pell Grant and...
The Office of Student Financial Services acknowledges the findings related to Reporting: Financial Reporting through the Common Origination and Disbursement (COD) System. We recognize the importance of accurate and timely reporting of origination data to ensure compliance with federal Pell Grant and Direct Loan requirements. The Office of Student Financial Services will implement additional controls to ensure accuracy of origination and disbursement reporting to COD. Prior to submission, staff will review enrollment dates, academic year dates, and disbursement dates against the academic calendar and student records in Colleague. A second-level review will be performed for a sample of records each term. Written procedures will be updated to document required verification steps before transmitting data to COD. Training will be provided to staff responsible for COD processing. These actions are intended to correct the issues contributing to this repeat finding, strengthen reporting accuracy, and ensure continued compliance with COD reporting requirements.
The Office of Student Financial Services acknowledges the finding and will implement corrective actions to ensure full compliance regarding Year-Round Pell Grant eligibility. To address the issue, enhanced processes and internal controls will be established to ensure all eligible students are accura...
The Office of Student Financial Services acknowledges the finding and will implement corrective actions to ensure full compliance regarding Year-Round Pell Grant eligibility. To address the issue, enhanced processes and internal controls will be established to ensure all eligible students are accurately identified for Summer Pell Grant disbursements. The Office of Student Financial Services will implement enhanced procedures to ensure all eligible students are properly identified for Year-Round Pell Grant awards. Each term, a review report will be generated to identify summer enrollees who received Pell Grant funding during the fall and/or spring terms. Financial aid staff will assess eligibility prior to disbursement by verifying enrollment intensity, cost of attendance, and remaining annual Pell eligibility. Written procedures will be updated to require a Pell eligibility review before processing any summer disbursements. The Director of Financial Aid will review the report each term to monitor compliance with these procedures.
Finding 2025-002 – Earmarking (Significant Deficiency) View of Responsible Official: Management concurs with the finding. Management costs charged to the FEMA award exceeded the 5% statutory cap. Management has implemented enhanced monitoring procedures to track cumulative management costs against t...
Finding 2025-002 – Earmarking (Significant Deficiency) View of Responsible Official: Management concurs with the finding. Management costs charged to the FEMA award exceeded the 5% statutory cap. Management has implemented enhanced monitoring procedures to track cumulative management costs against total FEMA obligated amounts on a recurring basis and to review compliance with the statutory limitation before additional amounts are submitted or recorded. Specifically, management will maintain a calculation of the allowable management cost cap based on total FEMA obligations, reconcile cumulative management costs recorded to that cap, and require supervisory review of the calculation and supporting documentation prior to submission of future claims and during period-end close. Management will also review the amount identified as questioned costs and work with the appropriate parties to resolve the excess amount in accordance with applicable grant requirements. Responsible Parties: Director of Finance, Vice President of Finance Anticipated Completion Date: June 30, 2026
Management response Finding 2025-001 – Allowability and Period of Performance (Material Weakness) View of Responsible Official: Management concurs with the finding. During the audit period, controls over payroll documentation for FEMA-related labor costs were not sufficiently designed and documented...
Management response Finding 2025-001 – Allowability and Period of Performance (Material Weakness) View of Responsible Official: Management concurs with the finding. During the audit period, controls over payroll documentation for FEMA-related labor costs were not sufficiently designed and documented to demonstrate independent supervisory review and approval of timecards, nor were controls in place to evidence review of wage rates for reasonableness prior to charging labor costs to the award. Management has strengthened its control procedures. Supervisors are required to review and approve employee timecards each pay period in UKG, and compliance with timecard approval is monitored through exception reporting provided to management. In addition, management has implemented a review control over wage rates charged to FEMA claims to verify that rates used are supported and reasonable in accordance with applicable Uniform Guidance requirements and internal policy. These controls will be documented and retained as part of the support for future federal award reporting. Responsible Parties: Payroll Manager, Director of Finance, Vice President of Finance Anticipated Completion Date: Complete
The DCR's management acknowledged the delay in preparing and retaining OP-15 documentation and stated that the Department's immediate priority was to ensure that employees received their authorized salary increases in a timely manner. To address this priority, management updated the internal payroll...
The DCR's management acknowledged the delay in preparing and retaining OP-15 documentation and stated that the Department's immediate priority was to ensure that employees received their authorized salary increases in a timely manner. To address this priority, management updated the internal payroll database by developing an electronic listing of affected employees and implementing approved salary changes directly within the system. Management indicated that this approach ensured that employees were compensated in accordance with approved salary adjustments, although the supporting documentation in personnel files lagged behind. Management further indicated that corrective efforts are currently underway to address a more recent, similar personnel action involving fewer than 50 employees and that, upon completion, the Department intends to proceed with preparing the OP-15 forms related to the broader population of over 4,000 employees. Management expects to complete the preparation and filing of the outstanding OP-15 documentation prior to the end of fiscal year 2026.
Weatherization Assistance Program (ALN 81.042) Low-Income Home Energy Assistance (ALN 93.568) U.S. Department of Energy U.S. Department of Health and Human Services State of Vermont Agency of Human Services Finding 2025-003 Compliance Finding - Eligibility Views of Responsible Officials Management a...
Weatherization Assistance Program (ALN 81.042) Low-Income Home Energy Assistance (ALN 93.568) U.S. Department of Energy U.S. Department of Health and Human Services State of Vermont Agency of Human Services Finding 2025-003 Compliance Finding - Eligibility Views of Responsible Officials Management acknowledges the eligibility determination error involving a two-unit dwelling and agrees that eligibility verification procedures were not sufficiently applied in accordance with DOE requirements for multiunit properties. The Organization takes this finding seriously and is committed to strengthening controls to prevent recurrence. The Organization is actively working with the pass-through entity to resolve the questioned costs of $4,048.39 and will repay any disallowed costs as required. Corrective Action Plan 1. Multi-Unit Eligibility Control Protocol A new Multi-Unit Eligibility Determination Checklist has been implemented requiring: • Individual income verification for each unit • Calculation worksheet demonstrating compliance with: o 66% rule, OR o 50% rule (where applicable), OR o HUD categorical eligibility per WPN 22-5 • Written supervisory approval prior to job authorization No multi-unit property may proceed to audit or production until eligibility documentation is approved. 2. Pre-Service Supervisory Approval Requirement • All multi-unit eligibility determinations must be reviewed and signed by: o Will Eberle (Weatherization Director) • Documentation must be verified before work order issuance. This adds a preventive control prior to expenditure of funds. 3. Executive Oversight Review • Will Eberle (Weatherization Director) will receive a monthly eligibility compliance report. • Any exceptions will trigger immediate review. • Quarterly summary reporting will be presented to senior leadership. 4. Targeted Eligibility Training • Staff will complete focused training on: o DOE WAP multi-family eligibility requirements o Income documentation standards o HUD categorical eligibility • Training will be conducted within 45 days and annually thereafter. • Attendance logs and materials will be maintained by Scott Hall. 5. File Audit & Continuous Monitoring • Will Eberle (Weatherization Director) will conduct monthly random sampling of: o 100% of multi-unit approvals for the next 6 months o Minimum 20% thereafter • Findings will be documented and tracked. 6. Resolution of Questioned Costs • The Organization is in communication with the pass-through entity regarding the $4,048.39 in questioned costs. • Repayment will occur promptly if required. • A repayment tracking file will be maintained by finance and reviewed by Chris Locarno. Implementation Timeline Summary Action, Responsible Party, Completion Target: Multi-unit checklist implemented, Scott Hall, Completed Supervisory sign-off requirement, Scott Hall, Immediate Staff eligibility training, Scott Hall, Within 45 days Executive reporting framework, Chris Locarno Completed Monthly sampling audits, Will Eberle, Ongoig Resolution of questioned costs WX Finance / Chris Locarno, Within 90 days Statement of Commitment The Organization is committed to restoring and maintaining full compliance with all federal and state Weatherization program requirements. Leadership, including, but not limited to: Will Eberle (Weatherization Director), Scott Hall (Weatherization Associate Director), and Chris Locarno (Business Manager), has implemented structural safeguards, enhanced supervisory review, and reinforced a culture of compliance and accountability to ensure that these deficiencies do not recur. Management believes the corrective actions outlined above address both the immediate deficiencies and the underlying control weaknesses identified in the audit. Responsible Person: Will Eberle Date of Completion: April 1, 2026
The District will ensure that proper semi-annual certifications or other time and effort documentation are prepared timely and properly maintained.
The District will ensure that proper semi-annual certifications or other time and effort documentation are prepared timely and properly maintained.
Elk City Public Schools will ensure that on all future construction contracts that deal with federal awards, requirements of the Davis-Bacon Act will be included. Prevailing wages will be inserted into the language of the contract and shall be signed by contractors and subcontractors. All contracts ...
Elk City Public Schools will ensure that on all future construction contracts that deal with federal awards, requirements of the Davis-Bacon Act will be included. Prevailing wages will be inserted into the language of the contract and shall be signed by contractors and subcontractors. All contracts will also spell out weekly reporting requirements of certified wages paid by contractors and subcontrators. In addition, ECPS will ensure that Davis-Bacon information is posted at all job sites. These policy changes will be implemented immediately and be in place as of October 9, 2025.
Condition: Out of 40 students tested for Return to Title IV, we identified 3 students whose calculations were not performed timely. Planned Corrective Action: Financial Aid has reviewed our current practices and will implement centralized accountability processes, using the Banner system and associa...
Condition: Out of 40 students tested for Return to Title IV, we identified 3 students whose calculations were not performed timely. Planned Corrective Action: Financial Aid has reviewed our current practices and will implement centralized accountability processes, using the Banner system and associated reports, to monitor all types of student withdrawal and drop determinations, as well as the corresponding R2T4 deadlines. Standardized procedures and a comprehensive processing checklist will be developed to ensure accuracy and timely completion. Staff in both offices will be trained on the updated procedures. Financial Aid will also continue working with the Registrar’s Office to ensure the receipt of accurate and timely enrollment data necessary to meet all Title IV requirements and deadlines. Contact person responsible for corrective action: Shashanta S James, Director Lana Greaves, Sr. Associate Director Anticipated Completion Date: April 15, 2026
Condition: Of the 40 students selected for enrollment reporting testing, the University did not properly update the student enrollment information for 3 students accurately. Root Cause: Manual NSC updates were overwritten by subsequent certified enrollment files. Planned Corrective Action: Western M...
Condition: Of the 40 students selected for enrollment reporting testing, the University did not properly update the student enrollment information for 3 students accurately. Root Cause: Manual NSC updates were overwritten by subsequent certified enrollment files. Planned Corrective Action: Western Michigan University has discontinued the use of manual enrollment status updates in the NSC Student Look-Up tool for unofficial withdrawals. The Registrar’s Office now records last date of attendance and withdrawal status directly in the SIS for all students who earn all E and X grades and are determined to have unofficially withdrawn. All unofficial withdrawal records are included in the final enrollment submission for the term, ensuring that withdrawal status and effective dates are transmitted through certified batch files to NSC and NSLDS. Contact person responsible for corrective action: Registrar, Carrie Cumming Assistant Registrar of Academic Records, Nicole Miller Anticipated Completion Date: 08/20/2025 (This is the day we sent summer II 2025 final enrollment to the NSC. Summer II 2025 LDA changes were completed directly into the SIS.)
Views of Responsible Officials and Planned Corrective Actions: We agree with the recommendation and will 1) develop and adopt written policies, procedures, and standards of conduct in compliance with the Uniform Guidance, and 2) initiate ongoing grant training for applicable personnel.
Views of Responsible Officials and Planned Corrective Actions: We agree with the recommendation and will 1) develop and adopt written policies, procedures, and standards of conduct in compliance with the Uniform Guidance, and 2) initiate ongoing grant training for applicable personnel.
Condition: Northeastern Illinois University (University) did not report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for the Higher Education Institutional Aid grants. Planned Corrective Action: The University wil...
Condition: Northeastern Illinois University (University) did not report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for the Higher Education Institutional Aid grants. Planned Corrective Action: The University will review applicable guidelines and assign the responsibility to the appropriate office. Contact person responsible for corrective action: Jannica Henry, Controller’s Office Anticipated Completion Date: 6/30/2026
Responsible Executive: CEO – Carmela Slivinski Implementation Status: Effective Immediately Full Implementation Date: No later than June 30, 2026 Finding — Compliance (Period of Performance) Significant Deficiency Condition: Auditor noted while testing period of performance, 1 of the 10 expenses rec...
Responsible Executive: CEO – Carmela Slivinski Implementation Status: Effective Immediately Full Implementation Date: No later than June 30, 2026 Finding — Compliance (Period of Performance) Significant Deficiency Condition: Auditor noted while testing period of performance, 1 of the 10 expenses recorded in June 2025 pertained to subsequent months outside of the contract period. Effect: One expense was included in the expenditure report under the incorrect grant period ending June 30, 2025. Cause: The Organization noted that this finding came about due to a clerical error. The bookkeeper inadvertently recorded a July invoice on June 30th and this led to an incorrect charge to the grant period ending June 30th. Recommendation: Auditor recommends management continue to perform a second review on the grant submission especially towards the end of the grant period. Management’s Response: Management concurs with the finding regarding deficiencies in grant period-of-performance compliance. Corrective Action Plan - Review existing Accounts Payable and Accounting Controls processes and revise as needed to ensure expenses are recorded as required. - Staff Training and Competency Development conducted annually to review accounting controls and ensure accounting personnel understand period of performance grant compliance requirements. - Ongoing Monitoring and Internal Compliance Review conducted periodically to ensure oversight of financial controls and grant compliance.
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of do...
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of documentation supporting grant deliverables and required progress reports. The procedures will include, at a minimum, the following: • Define required documentation, storage location, staff responsibilities, and retention requirements. • Require all supporting documentation to be maintained in a designated centralized repository and ensure documentation is complete, organized, and readily accessible for review. • Detail the steps during staff transitions that new staff must follow to access, maintain, and update grant-related documentation, ensuring consistency and completeness of records. VPDCP will perform periodic reviews of the centralized repository and formally document and sign-off on the reviews to verify that required documentation is maintained. 3. Anticipated implementation date: June 19, 2026
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement p...
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement procedures and controls to ensure pre-approval in accordance with the Uniform Guidance compliance requirements.
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement p...
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement procedures for review and reconciliation of lunch count data with claims reports in accordance with the Uniform Guidance.
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and document...
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and documenting submission. Management expects these procedures to be implemented beginning in the next reporting cycle. Management has subsequently completed and submitted all of the required performance reports to remedy the identified deficiency.
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvement...
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2026
Condition: Of the 40 students selected for enrollment reporting, the College did not update the student enrollment information for 3 students accurately. Planned Corrective Action: The College will modify its process and update its documented procedures to include periodically running an Enrollment ...
Condition: Of the 40 students selected for enrollment reporting, the College did not update the student enrollment information for 3 students accurately. Planned Corrective Action: The College will modify its process and update its documented procedures to include periodically running an Enrollment Reporting Graduated/Withdrawn Report from NLSDS and review for accuracy and make timely corrections, if necessary. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: June 30, 2026
Condition: The College did not have appropriate segregation of duties in place to ensure the reporting to COD is being reviewed by an individual separate from the process of preparing the reconciliations. Planned Corrective Action: The College will modify its process and update its documented proced...
Condition: The College did not have appropriate segregation of duties in place to ensure the reporting to COD is being reviewed by an individual separate from the process of preparing the reconciliations. Planned Corrective Action: The College will modify its process and update its documented procedures to include an appropriate review of the reconciliation by an individual separate from the process of preparing the reconciliations. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: June 30, 2026
Condition: The College did not provide notifications to certain students related to direct loan disbursements. Planned Corrective Action: The Director of Financial Aid will work with our information technology department to ensure the criteria used for triggering the notification emails is correct a...
Condition: The College did not provide notifications to certain students related to direct loan disbursements. Planned Corrective Action: The Director of Financial Aid will work with our information technology department to ensure the criteria used for triggering the notification emails is correct and capturing all the necessary students. Additionally, an exception report will be created to identify students who have not been sent the notification email for the financial aid department to review and then send the appropriate notification. The department procedures will be updated to reflect these changes in process. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: March 31, 2026
Condition: Out of 60 students tested for return to Title IV, we identified 4 students whose calculations were performed outside of the required time frame. Planned Corrective Action: The College will work with its Director of Financial Aid to ensure the semester end procedures include steps to ident...
Condition: Out of 60 students tested for return to Title IV, we identified 4 students whose calculations were performed outside of the required time frame. Planned Corrective Action: The College will work with its Director of Financial Aid to ensure the semester end procedures include steps to identify those students who unofficially withdrew. Once the students are identified, individuals with appropriate skills and knowledge will be able to determine if a return of Title IV calculation is necessary and appropriately return any funds, as necessary. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: March 31, 2026
Contact Person – Sue Chase, Superintendent Corrective Action Plan – The District should implement policies and procedures to ensure only allowable activities/costs are being charged against grants. Completion Date – March 31, 2026
Contact Person – Sue Chase, Superintendent Corrective Action Plan – The District should implement policies and procedures to ensure only allowable activities/costs are being charged against grants. Completion Date – March 31, 2026
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