Corrective Action Plans

Finding 1180982 (2025-003)

Material Weakness 2025

NJ

Special Tests & Provisions Questioned Costs Student Financial Aid

Views of Responsible Officials: The College acknowledges the audit finding that Return of Title IV (R2T4) calculations were not accurately completed for nine of the sixty students sampled, and that Title IV funds were not returned timely for fifteen of the sixty students sampled. During the audit pe...

Views of Responsible Officials: The College acknowledges the audit finding that Return of Title IV (R2T4) calculations were not accurately completed for nine of the sixty students sampled, and that Title IV funds were not returned timely for fifteen of the sixty students sampled. During the audit period, R2T4 tracking and oversight processes were in transition, which resulted in insufficient monitoring of calculation accuracy and timeliness. In addition, for several end-of-term cases involving unofficial withdrawals, the institution could not initiate R2T4 calculation until final grades were posted and an unofficial withdrawal determination was made based on non-passing (F) grades, in accordance with federal regulations governing unofficial withdrawals. The Fall 2024 semester ended on December 21st. The college was closed for the winter break and reopened January 2, 2025. Therefore, the Date of Determination (DOD) was not two days after the end of the semester but in January with the earliest available processing date being January 2, 2025. Corrective Action: The College has implemented enhanced internal controls to ensure compliance with Return of Title IV (R2T4) requirements. Responsibility for monitoring R2T4 calculations and timeliness has been assigned to the Director of Financial Aid and Compliance. A R2T4 tracking log has been established and is reviewed on a weekly basis to ensure that all official withdrawals are identified and processed within the required regulatory timeframe. For unofficial withdrawals, R2T4 calculations are initiated after the end of term once final grades are posted and an unofficial withdrawal date of determination (DOD) is made based on non-passing (F) grades, consistent with federal regulations. End-of-term R2T4 reviews for the fall semester are conducted upon return from winter break after the New Year to ensure complete and accurate academic records are available. Internal staff have received additional training on R2T4 regulatory requirements, timelines, and documentation standards. To ensure operational continuity, a senior specialist has been trained to manage R2T4 processing in the Director's absence. These corrective actions will strengthen internal controls and ensure accurate and timely processing of R2T4 calculations.

View Audit 392509

Finding 1180978 (2025-002)

Material Weakness 2025

Bergen Community College

NJ

Special Tests & Provisions Questioned Costs Student Financial Aid

Views of Responsible Officials: After consultation with the College’s Information Technology department, management determined that the file was processed and submitted on time. However, the NSLDS discrepancy resulted from a data processing issue during the March 2025 enrollment status download. Spe...

Views of Responsible Officials: After consultation with the College’s Information Technology department, management determined that the file was processed and submitted on time. However, the NSLDS discrepancy resulted from a data processing issue during the March 2025 enrollment status download. Specifically, while the NSLDS file was being generated, staff from another office were simultaneously accessing the same student records. These concurrent activities caused the affected students’ enrollment statuses to default to data from a prior download, resulting in incorrect reporting for the two records of the sixty examined. Corrective action: The College has revised its NSLDS data reporting process to prevent a recurrence of concurrent access. A static, saved population list is now used to generate NSLDS enrollment status downloads, eliminating conflicts caused by concurrent system access. This change ensures that enrollment status data is not impacted and remains consistent at the time of submission. Management believes this corrective action adequately addresses the identified issue, strengthens controls, mitigate this issue for future status change reports, and allows for accurate submission within the required 60-day timeframe.

View Audit 392509

Finding 1180972 (2025-012)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Corrective action plan: Long Term Care Regulation will enhance existing internal controls to ensure timely completion and distribution of Form 2567 to the providers. Implementation date: March 31, 2026 Responsible person: Michelle Dionne-Vahalik, Associate Commissioner, Long Term Care Regulations

View Audit 392506

Finding 1180968 (2025-011)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to...

Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to federal and state requirements. • Will establish an inventory of systems to ensure information owners and custodians are assigned. • Will create an automated compliance dashboard to facilitate monthly reporting to executive leadership. • Will prioritize high-risk Medicaid systems, targeting completion within three months and achieving full compliance with Texas Administrative Code (TAC) 202 requirements within twelve months. The Deputy Chief Information Officers (DCIO) and Chief Product Officers for System Applications, Public Health Applications, and Texas Integrated Eligibility Redesign System (TIERS)/Medicaid Enterprise Systems (MES) will provide support and assistance to the program areas in creating Plan of Actions and Milestones and completing risk assessments for all systems provided in the executive report for their respective areas related to the audit. Implementation date: February 28, 2027 Responsible persons: Anil Koindala, Chief Information Security Officer Leatha Marr, DCIO and Chief Product Officer, System Applications Madhavi Koganti, DCIO and Chief Product Officer, Public Health Applications James Huang, DCIO and Chief Product Officer, TIERS/MES

View Audit 392506

Finding 1180945 (2025-006)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Matching / Level of Effort / Earmarking Questioned Costs § 200.303

Corrective action plan: The Office of Area Agencies on Aging (OAAA) will update the General Revenue allocation procedures and workbook to allocate general revenue to Area Agencies on Aging (AAAs) in proportion to the associated federal awards to ensure they are not supplanting non-federal funds rela...

Corrective action plan: The Office of Area Agencies on Aging (OAAA) will update the General Revenue allocation procedures and workbook to allocate general revenue to Area Agencies on Aging (AAAs) in proportion to the associated federal awards to ensure they are not supplanting non-federal funds related to supportive services and senior centers. OAAA will provide in-service training for the OAAA Budget Analyst and Financial Analysts on the revised procedures and workbook. OAAA will provide training for AAAs on the revised procedures and workbook for managing Older Americans Act funds, General Revenue, and associated regulations. Implementation date: September 30, 2026 Responsible person: Lori Conner, Manager, OAAA Fiscal and Contract Oversight

View Audit 392506

Finding 1180922 (2025-005)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Matching / Level of Effort / Earmarking Questioned Costs

Corrective action plan: HHSC will discuss and make a decision on submitting a waiver request for the 10% setaside requirement. Implementation date: September 1, 2026 Responsible person: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations

View Audit 392506

Finding 1180919 (2025-004)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Matching / Level of Effort / Earmarking Questioned Costs Allowable Costs / Cost Principles § 200.303

Corrective action plan: HHSC will run quarterly expenditure reports for this grant to monitor administrative earmarking thresholds. Implementation date: July 31, 2026 Responsible person: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations

View Audit 392506

Finding 1180907 (2025-017)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Questioned Costs Cash Management Significant Deficiency § 200.303

Corrective action plan: The Department will enhance current procedures for the compilation and review of the Period 1 clearance pattern calculation in accordance with the Cash Management Improvement Act (CMIA) and as required in the Texas-State Agreement. The Manager of Accounting will use the State...

Corrective action plan: The Department will enhance current procedures for the compilation and review of the Period 1 clearance pattern calculation in accordance with the Cash Management Improvement Act (CMIA) and as required in the Texas-State Agreement. The Manager of Accounting will use the State Auditor Office’s template spreadsheet provided to agencies to calculate their annual Period 1 calculation and retain the worksheet as supporting documentation. The Director of Financial Administration will review the spreadsheet and calculation prior to CMIA certification. Implementation date: August 2026 Responsible persons: Jose Guevara, Director of Financial Administration Cristina Ortega, Manager of Accounting.

View Audit 392506

Finding 1180905 (2025-021)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Reporting Questioned Costs Special Tests & Provisions § 200.303

Corrective action plan: Vendor System Safeguards: TWC's I3 (Department of Analytics & Evaluation), IT (Information Technology), and WFA (Workforce Automation) resources will require our WorkInTexas.com vendor, Geographic Solutions Inc (GSI), to implement additional system safeguards to prevent the d...

Corrective action plan: Vendor System Safeguards: TWC's I3 (Department of Analytics & Evaluation), IT (Information Technology), and WFA (Workforce Automation) resources will require our WorkInTexas.com vendor, Geographic Solutions Inc (GSI), to implement additional system safeguards to prevent the duplication of hour entries when extracting data from the WIT system and creating files. TWC resources will maintain oversight of the implementation and ongoing effectiveness of these safeguards. Joint Anomaly Detection: TWC's I3 (Department of Analytics & Evaluation), IT (Information Technology), and WFA (Workforce Automation) resources will require our WorkInTexas.com vendor, Geographic Solutions Inc (GSI), to establish automated validation checks to identify anomalies such as duplicate lines, unexpected variances, and irregular hour totals prior to ingesting vendor files into TWC systems. TWC resources will maintain oversight of the implementation and ongoing effectiveness of these validation checks. TWC IT Data Reconciliation: TWC IT (Information Technology) will enhance supervisory review vendor procedures to reconcile data received from third-party vendors against source records, verifying completeness and accuracy before supplying to I3 (Department of Analytics & Evaluation) for inclusion in federal reporting. Implementation date: December 31, 2026 Responsible persons: Greg Waugh, Director, Workforce Automation (WFA), TWC Richard Yashewski, Director, IT Maintenance & Operations, TWC Geoffrey Miller, Director, Department of Analytics & Evaluation (I3), TWC

View Audit 392506

Finding 1180899 (2025-010)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Corrective action plan: HHSC will conduct an end-to-end review of the sanctions process to identify and implement any needed changes to the business process, training, or system. Implementation date: May 31, 2026 Responsible person: Carrie Robertson, Manager, Strategy and Innovation–Business Integra...

Corrective action plan: HHSC will conduct an end-to-end review of the sanctions process to identify and implement any needed changes to the business process, training, or system. Implementation date: May 31, 2026 Responsible person: Carrie Robertson, Manager, Strategy and Innovation–Business Integration and Support

View Audit 392506

Finding 1180893 (2025-008)

Material Weakness 2025

State of Texas C/o Comptroller of Public Accounts

TX

Questioned Costs Reporting Significant Deficiency § 200.302 § 200.303 § 200.329

Corrective action plan: HHSC has taken steps to improve the consistency and reliability of financial reporting related to Maintenance of Effort (MOE) expenditures, specifically, amounts reported on the ACF 204, submitted by HHSC Budget and the ACF 196R, submitted by HHSC Federal Reporting (FR). To a...

Corrective action plan: HHSC has taken steps to improve the consistency and reliability of financial reporting related to Maintenance of Effort (MOE) expenditures, specifically, amounts reported on the ACF 204, submitted by HHSC Budget and the ACF 196R, submitted by HHSC Federal Reporting (FR). To address potential discrepancies and strengthen internal controls, HHSC Federal Reporting has implemented and documented a formal reconciliation process. This process involves the following key components: • Implementation and documentation of a formal reconciliation process that compares all MOE expenditures for HHSC, TEA, and TWC reported on the ACF 204 to those reported on the ACF 196R before report submission. The process outlines specific steps for data cross-referencing and validation to ensure completeness and accuracy. • Research, resolve, and correct any discrepancies identified during the reconciliation process before the reports are finalized and submitted for management review. • Reinforcement of management review and documentation of the reconciliation between the ACF-204 and ACF-196R will be incorporated into the approval process prior to report certification. Implementation date: February 28, 2026 Responsible person: Alan Flynn, Manager, Federal Reporting

View Audit 392506

Finding 1180827 (2025-003)

Material Weakness 2025

La Roche University

PA

Questioned Costs Student Financial Aid

Condition The Federal Pell Grant for one student out of 27 sampled was calculated incorrectly, and the student received excess aid. Corrective Action Plan La Roche University concurs with the finding. The Office of Financial Aid has implemented enhanced controls to ensure accurate Federal Pell Grant...

Condition The Federal Pell Grant for one student out of 27 sampled was calculated incorrectly, and the student received excess aid. Corrective Action Plan La Roche University concurs with the finding. The Office of Financial Aid has implemented enhanced controls to ensure accurate Federal Pell Grant calculations in accordance with Title IV regulations and U.S. Department of Education Pell Grant payment and disbursement guidance. Immediate Correction of Identified Error The affected student’s Pell Grant award was recalculated using the correct Scheduled Pell amount and enrollment intensity. The overaward was resolved in accordance with federal overpayment and reconciliation requirements, and the Common Origination and Disbursement (COD) system was updated accordingly. Pell Calculation Verification Control A mandatory secondary review process has been implemented for all Pell-eligible students prior to disbursement to prevent future occurrences noted in this finding. This control collectively mitigates the risk of recurrence and strengthen institutional compliance with federal eligibility and disbursement requirements. Name(s) of Contact Person(s) Responsible for Corrective Action • Lawrence Britton, Executive Director of Financial Aid • Ron Elmore, Associate Director of Financial Aid Anticipated Completion Date All corrective actions were implemented as of February 9, 2026.

View Audit 392486

Finding 1180826 (2025-002)

Material Weakness 2025

La Roche University

PA

Student Financial Aid HUD Housing Programs Matching / Level of Effort / Earmarking

Condition The federal aid disbursed resulted in a credit balance for one of the 25 students tested were not returned within 14 days of the date the credit balance occurred. Corrective Action Plan La Roche University concurs with the finding. The University’s procedures did not allow for timely payme...

Condition The federal aid disbursed resulted in a credit balance for one of the 25 students tested were not returned within 14 days of the date the credit balance occurred. Corrective Action Plan La Roche University concurs with the finding. The University’s procedures did not allow for timely payment of the funds to the student due to holidays that occurred. The Office of Student Accounts has implemented enhanced controls to ensure that credit balances are reviewed and issued refunds in a timely manner. Name(s) of Contact Person(s) Responsible for Corrective Action • Frank Corona, Controller • Dayna Tinkey, Director of Student Accounts Anticipated Completion Date All corrective actions were implemented as of February 12, 2026.

View Audit 392486

Finding 1180821 (2025-002)

Material Weakness 2025

Stroudsburg Area School District

PA

Allowable Costs / Cost Principles Reporting Questioned Costs § 200.510

Significant Deficiency 2025-002 (Internal Control Over Federal Award Reporting – ESSER III) Federal Program: Education Stabilization Fund - ARP-ESSER ALN: 84.425U Condition: Allowable ESSER III expenditures incurred during fiscal year 2023-24 were not identified or included on the Schedule of Expend...

Significant Deficiency 2025-002 (Internal Control Over Federal Award Reporting – ESSER III) Federal Program: Education Stabilization Fund - ARP-ESSER ALN: 84.425U Condition: Allowable ESSER III expenditures incurred during fiscal year 2023-24 were not identified or included on the Schedule of Expenditures of Federal Awards (SEFA) for that year. In addition, expenditures related to Federal Set-Aside awards were mistakenly included in the Final Expenditure Report for ESSER III, resulting from a misunderstanding of the structure of the federal awards. Recommendation: Strengthen internal controls Corrective Action: The District will provide targeted training to staff responsible for federal grant accounting to ensure a clear understanding of federal grant award structures, including the distinction between ESSER III and related Federal Set-Aside awards. This training will cover grant setup, expenditure coding, and reporting requirements. Person Responsible: Brenda VanBuskirk, Business Manager Proposed Completion Date: December 31, 2025

View Audit 392478

Finding 1180782 (2025-002)

Material Weakness 2025

Community College District of Monroe County, Michigan

MI

Questioned Costs

We concur with the auditor’s recommendation to create a more formalized year end closing process that will ensure the trial balance has been adjusted for the year-end closing entries. Certain corrective actions have already started, and we anticipate having a formalized closing process in place for ...

We concur with the auditor’s recommendation to create a more formalized year end closing process that will ensure the trial balance has been adjusted for the year-end closing entries. Certain corrective actions have already started, and we anticipate having a formalized closing process in place for the items noted above by May 1, 2026.

View Audit 392448

Finding 1180762 (2025-001)

Material Weakness 2025

Federation of Appalachian Housing Enterprises, Inc.

KY

Subrecipient Monitoring Questioned Costs Reporting

Federation of Appalachian Housing Enterprises, Inc. acknowledges that we should have been filing information for all of our grantees over $30,000 on the FFATA Sub-award Reporting System website. We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the w...

Federation of Appalachian Housing Enterprises, Inc. acknowledges that we should have been filing information for all of our grantees over $30,000 on the FFATA Sub-award Reporting System website. We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the website, and we have included FFATA registration as a step in the creation of all future RDCA grantees.

View Audit 392447

Finding 1180751 (2025-002)

Material Weakness 2025

Western Technical College District

WI

Student Financial Aid Questioned Costs Reporting

Upon Notification of the situation by Wipfli, Western had identified several new processes to assure our students are being reported to NSLDS within the 60-day period. 1. Resolved: Western worked with Ellucian Services to review and update our savedlist for National Student Clearinghouse reporting. ...

Upon Notification of the situation by Wipfli, Western had identified several new processes to assure our students are being reported to NSLDS within the 60-day period. 1. Resolved: Western worked with Ellucian Services to review and update our savedlist for National Student Clearinghouse reporting. We discovered the savedlist excluded a subset of student, which prevented their enrollment from being updated correctly. The savedlist is now updated. 2. Update our Admissions Policy (E0200) and Procedure (E0200p9(1)) to direct students on how to officially withdraw from the College. This will help us identify students who do not plan to return to the College. We will create a report of students who officially withdraw from the College and update their status on National Student Clearinghouse website in a timely manner. 3. Identify a process to update the enrollment status for students who receive an extenuating drop for courses. We will develop a report to monitor and update on the National Student Clearinghouse website. 4. Identify a process to update the enrollment status for students who unofficially withdraw from a session 1 course which impacts their enrollment status. We will develop a report to monitor and update the National Student Clearinghouse website. Person Responsible: Lyndsey Thomas, Registrar Projected Completion Date: June 1, 2026

View Audit 392422

Finding 1180747 (2025-001)

Material Weakness 2025

Western Technical College District

WI

Questioned Costs Internal Control / Segregation of Duties

Issue identified: An Institution's written information security program must address the required minimum seven requirements of the Gramm-Leach Bliley Act. Program Affected: Student Financial Assistance Cluster Corrective Action: - Upon notification of the finding by Wipfli, Western is updating writ...

Issue identified: An Institution's written information security program must address the required minimum seven requirements of the Gramm-Leach Bliley Act. Program Affected: Student Financial Assistance Cluster Corrective Action: - Upon notification of the finding by Wipfli, Western is updating written policy/procedures to ensure that our written security program addresses all seven requirements of the Gramm-Leach Bliley policies. -We are running our penetration tests each quarter to ensure that we are maintaining security as needed in education at Western. -The internal testing and quarterly tests results we will be running will be performed during the last month of each quarter for review upon request. Person Responsible: Primary - Joan Pierce, CIO, Secondary - Michael Caretta, IT Director

View Audit 392422

Finding 1180720 (2025-001)

Material Weakness 2025

Riley House Non-Profi Housing Corporation

MA

Questioned Costs Material Weakness Reporting § 200.510

Planned Corrective Action: The new policy was discussed during the fiscal year for identifying federal awards. The written memo detailing the new policy was updated on September 30, 2025. This is the policy in place to be followed when preparing the schedule of expenditures of federal awards Contact...

Planned Corrective Action: The new policy was discussed during the fiscal year for identifying federal awards. The written memo detailing the new policy was updated on September 30, 2025. This is the policy in place to be followed when preparing the schedule of expenditures of federal awards Contact Person: Name: Brianne Hoelschen Title: Controller Phone: (617) 209-5222 Email: bhoelschen@maloneyproperties.com Completion Date: September 30, 2025

View Audit 392379

Finding 1180710 (2025-002)

Material Weakness 2025

National University of Natural Medicine

OR

Student Financial Aid Questioned Costs Subrecipient Monitoring § 200.516

Finding 2025-002 Reporting Department’s Response: Management agrees with this finding. Corrective Action: This issue arose during the onboarding of students admitted through a teach-out arrangement with a closing institution. Because these students entered under program structures that differed from...

Finding 2025-002 Reporting Department’s Response: Management agrees with this finding. Corrective Action: This issue arose during the onboarding of students admitted through a teach-out arrangement with a closing institution. Because these students entered under program structures that differed from NUNM’s standard enrollment models, some of the information initially received did not align with NUNM’s financial aid packaging assumptions. In two cases, cost of attendance calculations reflected full-time status when the program design required three-quarter-time treatment. While the situation was limited to a small number of students within a unique population, management recognizes that our internal coordination processes did not sufficiently account for the complexity of the teach-out transition. In particular, clearer confirmation of enrollment status and program structure should have occurred before aid was packaged and originated. Management is strengthening procedures for any future teach-out, transfer, or non-standard admissions cohorts to ensure accurate and compliant packaging from the outset. Going forward, NUNM will implement the following controls: • A standardized handoff process from Admissions to Financial Aid for special populations that documents program structure, term length, and expected enrollment level prior to packaging. • A secondary review requirement for initial aid awards for new program types or cohorts before loans are originated. • Regular cross-functional checkpoints between Admissions and Financial Aid during the setup of non-standard programs. Management views this experience as an opportunity to improve coordination and compliance during periods of institutional transition and is committed to maintaining strong controls over Title IV packaging and cost of attendance calculations. Contact: Jerry Bores Anticipated Completion Date: Immediately

View Audit 392354

Finding 1180655 (2025-003)

Material Weakness 2025

Ascentria Community Services, Inc.

MA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Health and Human Services U.S. Refugee Admissions Program - Assistance Listing No. 19.510 Recommendation: It is recommended that the Organization review controls in place to ensure payroll expenses are approved and maintain evidence of approval. Explanation of disagreement with au...

U.S. Department of Health and Human Services U.S. Refugee Admissions Program - Assistance Listing No. 19.510 Recommendation: It is recommended that the Organization review controls in place to ensure payroll expenses are approved and maintain evidence of approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing standard operating procedures with the program staff. All expenses will be supported with proper approvals. Management will perform periodic reviews to ensure expenses have evidence of approval. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris, Senior Director of Finance Planned completion date for corrective action plan: June 30, 2025 and Ongoing

View Audit 392325

Finding 1180654 (2025-002)

Material Weakness 2025

Ascentria Community Services, Inc.

MA

Questioned Costs Period of Performance Significant Deficiency

U.S. Department of State U.S. Refugee Admissions Program - Assistance Listing No. 19.510 Recommendation: It is recommended that the Organization review controls in place to ensure expenses are approved and maintain evidence of approval. Explanation of disagreement with audit finding: There is no dis...

U.S. Department of State U.S. Refugee Admissions Program - Assistance Listing No. 19.510 Recommendation: It is recommended that the Organization review controls in place to ensure expenses are approved and maintain evidence of approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing standard operating procedures with the program staff. All expenses will be supported with proper approvals. Management will perform periodic reviews to ensure expenses have evidence of approval. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris, Senior Director of Finance Planned completion date for corrective action plan: June 30, 2025 and Ongoing

View Audit 392325

Finding 1180653 (2025-001)

Material Weakness 2025

Ascentria Community Services, Inc.

MA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Health and Human Services and U.S Department of State Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 U.S. Refugee Admissions Program - Assistance Listing No. 19.510 Recommendation: It is recommended that the Organizati...

U.S. Department of Health and Human Services and U.S Department of State Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 U.S. Refugee Admissions Program - Assistance Listing No. 19.510 Recommendation: It is recommended that the Organization review controls in place to ensure expenses are approved and maintain evidence of approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing standard operating procedures with the program staff. All expenses will be supported with proper approvals. Management will perform periodic reviews to ensure expenses have evidence of approval. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris, Senior Director of Finance Planned completion date for corrective action plan: June 30, 2025 and Ongoing

View Audit 392325

Finding 1180594 (2025-027)

Material Weakness 2025

Nevada System of Higher Education

NV

Allowable Costs / Cost Principles Questioned Costs

Period of Performance Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Prospectively, UNLV Health will ensure that expenditures are charged to the gra...

Period of Performance Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Prospectively, UNLV Health will ensure that expenditures are charged to the grant within the correct period. UNLV Health will be updating the template for payroll hours to ensure only time from the invoiced month is captured. ● How compliance and performance will be measured and documented for future audit, management and performance review. The UNLV Health Finance Administrator and Accounting department will continue to review and approve the completed template along with supporting documentation, including ADP reports. Signed invoices will serve as the documentation that these were reviewed and approved. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV Health Accounting department is accountable for maintaining and approving documents. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu

View Audit 392299

Finding 1180593 (2025-026)

Material Weakness 2025

Nevada System of Higher Education

NV

Allowable Costs / Cost Principles Questioned Costs

Allowable Costs/Cost Principles Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV Health is implementing a process to require employees to certify...

Allowable Costs/Cost Principles Responses UNLV Health agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV Health is implementing a process to require employees to certify time spent working on a grant. They will sign a timesheet at the end of the month. UNLV Health will then true-up the payroll costs allocated to the grant with the actual time spent for employees charged to the program on a quarterly basis. ● How compliance and performance will be measured and documented for future audit, management and performance review. Program administrators will provide the UNLV Health Finance Administrator and Accounting department with the support documentation from the EMR system. UNLV Health Finance Administrators and accounting will continue to review all support documentation for compliance and performance. The grant expenditures details are maintained and tracked via spreadsheet. Additionally, the State also conducts independent audits and UNLV Health received a clean audit from the State for this specific grant in FY24. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV Health Accounting department is accountable for maintaining and approving documents. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu

View Audit 392299

Corrective Action Plans

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