Corrective Action Plans

Finding 1179751 (2025-053)

Material Weakness 2025

State of Nebraska

NE

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment

Program: AL 93.778 – Grants to States for Medicaid – Special Tests and Provisions Corrective Action Plan: The Agency will begin completing desk reviews on the state-owned facility. The Agency will continue to select high risk facilities for field audit examinations based on their risk identified dur...

Program: AL 93.778 – Grants to States for Medicaid – Special Tests and Provisions Corrective Action Plan: The Agency will begin completing desk reviews on the state-owned facility. The Agency will continue to select high risk facilities for field audit examinations based on their risk identified during the initial desk reviews. Contact: Jerry Vanderbeek Anticipated Completion Date: June 30, 2026

View Audit 392165

Finding 1179750 (2025-052)

Material Weakness 2025

State of Nebraska

NE

Allowable Costs / Cost Principles Eligibility Reporting

Program: AL 93.778 – Grants to States for Medicaid – Allowability & Eligibility Corrective Action Plan: Medicaid eligibility program accuracy unit plans to update internal eligibility staff training, guidance, and communication related to working vital statistics NFOCUS notices as applicable. Indivi...

Program: AL 93.778 – Grants to States for Medicaid – Allowability & Eligibility Corrective Action Plan: Medicaid eligibility program accuracy unit plans to update internal eligibility staff training, guidance, and communication related to working vital statistics NFOCUS notices as applicable. Individual staff who made errors will receive additional training to ensure they understand policies and procedures going forward. Additionally, the program accuracy unit, responsible for quality control case reviews, will begin the ongoing monitoring of both date of death records and actions taken as a result of notices of death. The Medicaid division is collaborating with the DHHS Information Systems and Technology team to perform root cause analysis for Vital Statistic records that may not have triggered automated case notices, and to evaluate system related internal control improvement opportunities. Contact: Jeremy Brunssen, Tiffanie Green, Anne Harvey Anticipated Completion Date: June 30, 2026

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Finding 1179749 (2025-051)

Material Weakness 2025

State of Nebraska

NE

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Program: AL 93.778 – Grants to State for Medicaid – Allowability Corrective Action Plan: This issue arose from an oversight: Optum’s rate sheet listed calendar-year 2022 dates, but the rates corresponded to 2023. As a result of this error in the file received from Optumas, staff mistakenly processed...

Program: AL 93.778 – Grants to State for Medicaid – Allowability Corrective Action Plan: This issue arose from an oversight: Optum’s rate sheet listed calendar-year 2022 dates, but the rates corresponded to 2023. As a result of this error in the file received from Optumas, staff mistakenly processed the 2022 capitation adjustment using the 2023 rates. The overcharged Federal amount will be refunded to CMS. Contact: Snita Soni Anticipated Completion Date: April 30, 2026

View Audit 392165

Finding 1179748 (2025-050)

Material Weakness 2025

State of Nebraska

NE

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Program: AL 93.778 – Grants to States for Medicaid – Allowability & Eligibility Corrective Action Plan: The Agency has standard operating processes and procedures however worker error resulted in these conditions. The Agency will ensure established standard processes are followed. Additionally, user...

Program: AL 93.778 – Grants to States for Medicaid – Allowability & Eligibility Corrective Action Plan: The Agency has standard operating processes and procedures however worker error resulted in these conditions. The Agency will ensure established standard processes are followed. Additionally, user guides and training materials will be reviewed and updated if deemed necessary for clarity. New guidance material will be issued if deemed necessary. Individual staff who made the errors will be followed up with to ensure they understand the policies. Contact: Tiffanie Green Anticipated Completion Date: June 30, 2026

View Audit 392165

Finding 1179746 (2025-048)

Material Weakness 2025

State of Nebraska

NE

Questioned Costs Eligibility Internal Control / Segregation of Duties

Program: AL 93.778 – Grants to States for Medicaid – Allowability & Eligibility Corrective Action Plan: The Agency has standard processes and procedures for processing renewals timely and updating budgets to reflect changes that have occurred within a household; however, worker errors resulted in th...

Program: AL 93.778 – Grants to States for Medicaid – Allowability & Eligibility Corrective Action Plan: The Agency has standard processes and procedures for processing renewals timely and updating budgets to reflect changes that have occurred within a household; however, worker errors resulted in these conditions. The Agency will ensure established standard processes are followed. Additionally, user guides and training materials will be reviewed and updated if deemed necessary for clarity. Individual staff who made the errors will be followed up with to ensure they understand the policies. Contact: Tiffanie Green Anticipated Completion Date: June 30, 2026

View Audit 392165

Finding 1179745 (2025-047)

Material Weakness 2025

State of Nebraska

NE

Questioned Costs Allowable Costs / Cost Principles Eligibility

Program: AL 93.778 – Grants to States for Medicaid – Allowability Corrective Action Plan: DHHS and Medicaid and Long-Term Care (MLTC) have been actively implementing procedures and controls to ensure that payments are allowable, adequately supported, and in accordance with State and Federal regulati...

Program: AL 93.778 – Grants to States for Medicaid – Allowability Corrective Action Plan: DHHS and Medicaid and Long-Term Care (MLTC) have been actively implementing procedures and controls to ensure that payments are allowable, adequately supported, and in accordance with State and Federal regulations. As noted in the early management letter, the findings and conditions are consistent with findings from prior year(s) audits. As a result, the department had already taken significant actions throughout State Fiscal Year 2025 to implement several procedures and controls which are expected to mitigate the majority of the conditions observed in the audit. Specifically, in late February 2025, MLTC implemented systematic controls to require that GPS/IVR visit verification and recipient signature is captured for visits to be submitted for claim payment. Additional changes included tightening down, or reducing, the radius of the geofence area for location verification. Additionally, in late June 2025, the department implemented additional, significant procedures and controls which include the requirement of all PAS and Home and Community Based caregivers and providers obtain and use their unique National Provider Identifier (NPI) on all visits and claims for visits to be submitted for claim payment, new systematic controls that do not allow for unreasonable billing of units/hours in a day on both a client and caregiver level, and new controls that parse the client authorizations into weekly segments which create limits for the number of hours/units per week that can be billed for services for a client, based on the authorized amounts in the client assessment. DHHS and MLTC will continue to monitor data and claims and identify and evaluate opportunities to implement additional controls and procedures that ensure payments for these services are allowable and in accordance with State and Federal regulations. In addition to the changes in MLTC, the following actions are being implemented by Child and Family Services (CFS). CFS will collaborate with the Nebraska State Patrol to develop an automated process to compare the addresses of foster parents with the Sex Offender Registry on a quarterly basis to ensure that no registered sex offenders reside at the same household address as a ward of the state. Additionally, Agency-Supported Foster Care contracts and Relative/Kinship Caregiver Agreements will be amended to include a requirement that caregivers report all criminal citations, charges, convictions, and any individuals who have moved into the home within five (5) business days to CFS. Finally, Foster Care Regulations require background checks for all individuals in the foster home who are 18 years of age and older. There are certain crimes that make a person ineligible to provide foster care, while other criminal convictions fall under the discretionary category. To ensure consistency, CFS has centralized the review and approval of discretionary convictions that are not subject to mandatory exclusion. Contact: Jeremy Brunssen, MLTC Kathleen Stolz, CFS Anticipated Completion Date: 6/30/2026 (ongoing)

View Audit 392165

Finding 1179736 (2025-045)

Material Weakness 2025

State of Nebraska

NE

Internal Control / Segregation of Duties Questioned Costs Matching / Level of Effort / Earmarking

Program: AL 93.659 – Adoption Assistance – Allowability Corrective Action Plan: The Agency will evaluate and develop new processes to review and ensure that attendance records match billing documents, authorizations, and claims. An evaluation of the Provider Portal will be completed to identify enha...

Program: AL 93.659 – Adoption Assistance – Allowability Corrective Action Plan: The Agency will evaluate and develop new processes to review and ensure that attendance records match billing documents, authorizations, and claims. An evaluation of the Provider Portal will be completed to identify enhancements to this area. The Agency will develop a new fraud prevention process for the Resource Development team to enhance controls over attendance, billing, and the auditing of provider claims, and to ensure compliance. A Provider Probation process will be implemented to address identified billing concerns. Contact: Nicole Vint Anticipated Completion Date: September 30, 2026

View Audit 392165

Finding 1179731 (2025-042)

Material Weakness 2025

State of Nebraska

NE

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Program: AL 93.658 – Foster Care Title IV-E – Allowability Corrective Action Plan: The Agency will evaluate and develop new processes to review and ensure that attendance records match billing documents, authorizations, and claims. An evaluation of the Provider Portal will be completed to identify e...

Program: AL 93.658 – Foster Care Title IV-E – Allowability Corrective Action Plan: The Agency will evaluate and develop new processes to review and ensure that attendance records match billing documents, authorizations, and claims. An evaluation of the Provider Portal will be completed to identify enhancements to this area. The Agency will develop a new fraud prevention process for the Resource Development team to enhance controls over attendance, billing, and the auditing of provider claims, and to ensure compliance. A Provider Probation process will be implemented to address identified billing concerns. Contact: Nicole Vint Anticipated Completion Date: September 30, 2026

View Audit 392165

Finding 1179726 (2025-041)

Material Weakness 2025

State of Nebraska

NE

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

Program: AL 93.575 and 93.596 – CCDF Cluster – Special Tests and Provisions Corrective Action Plan: DHHS will continue to communicate with State Fire Marshall (SFM), Nebraska Department Water, Energy, and Environment (DWEE) Agency, and delegated authorities regarding expectations and timeframes for ...

Program: AL 93.575 and 93.596 – CCDF Cluster – Special Tests and Provisions Corrective Action Plan: DHHS will continue to communicate with State Fire Marshall (SFM), Nebraska Department Water, Energy, and Environment (DWEE) Agency, and delegated authorities regarding expectations and timeframes for fire and sanitation inspections. DHHS is establishing quarterly meetings with SFM, DWEE, and delegated authorities to review overdue routine inspections, address issues, and collaborate on best practices. Quarterly meetings have been established with DWEE as of January 2025. DHHS will work with SFM and local delegates to establish regular meetings. As part of the regular meetings, DHHS will address overdue fire and sanitation inspections individually to establish reason for delay of the required inspections. DHHS Child Care Inspection Specialists conduct inspections that occur annually at a minimum and which address regulatory requirements that address a healthy and safe child care environment. If serious fire and sanitation concerns are observed at any inspection that may endanger the health and safety of children in care, DHHS will work with the appropriate authority to request an immediate inspection. SFM, DWEE, or delegated authorities always respond timely to these immediate requests. DHHS referral and follow-up procedures will be reviewed with staff and reemphasized. Due to turnover and retirement of three Child Care Licensing Supervisors, five Child Care Inspection Specialists, and two Administrative Specialist over the last two years, fire and sanitation referral procedures and follow-ups were assigned to now departed staff whose referral and follow-up records are unavailable. DHHS will continue to explore contractual options with SFM, DWEE, and delegated authorities for fire and sanitation inspections. DHHS will continue to explore statutory, regulatory and/or contract options to place more accountability on the licensee and referred agencies for maintaining current fire and sanitation approvals. DHHS will continue to implement policies and procedures for file reviews by Child Care Licensing Supervisors (CCLS). The Program Manager will reestablish file reviews that were not done consistently due to turnover in which all three Child Care Licensing Supervisors (CCLS) retired or left in the last 24 months. DHHS will continue to complete the statutory child care inspection requirements. Contact: Lindsy Braddock; Matthew Hayden Anticipated Completion Date: September 30, 2026

View Audit 392165

Finding 1179725 (2025-038)

Material Weakness 2025

State of Nebraska

NE

Matching / Level of Effort / Earmarking Questioned Costs Eligibility

Program: AL 93.575 and 93.596 – CCDF Cluster – Allowability & Eligibility & Matching Corrective Action Plan: The Agency will evaluate and develop new processes to review and ensure that attendance records match billing documents, authorizations, and claims. An evaluation of the Provider Portal will ...

Program: AL 93.575 and 93.596 – CCDF Cluster – Allowability & Eligibility & Matching Corrective Action Plan: The Agency will evaluate and develop new processes to review and ensure that attendance records match billing documents, authorizations, and claims. An evaluation of the Provider Portal will be completed to identify enhancements to this area. The Agency will develop a new fraud prevention process for the Resource Development team to enhance controls over attendance, billing, and the auditing of provider claims, and to ensure compliance. A Provider Probation process will be implemented to address identified billing concerns. The Agency will evaluate current regulations and requirements surrounding provider rate increases related to the Step Up to Quality provider rate enhancements and develop a process to address concerns with exceeding private pay rates. Contact: Nicole Vint Anticipated Completion Date: September 30, 2026

View Audit 392165

Finding 1179723 (2025-039)

Material Weakness 2025

State of Nebraska

NE

Questioned Costs Subrecipient Monitoring Period of Performance § 200.521

Program: AL 93.575 – COVID-19 Child Care and Development Block Grant – Period of Performance Corrective Action Plan: N/A Contact: Heather Arnold Anticipated Completion Date: Complete

View Audit 392165

Finding 1179711 (2025-031)

Material Weakness 2025

State of Nebraska

NE

Eligibility Questioned Costs Matching / Level of Effort / Earmarking

Program: AL 93.566 – Refugee and Entrant Assistance State/Replacement Designee Administered Programs – Allowability & Eligibility Corrective Action Plan: The Refugee Resettlement Program has requested eligibility system changes to prevent eligibility errors. In addition, the Refugee Resettlement Pro...

Program: AL 93.566 – Refugee and Entrant Assistance State/Replacement Designee Administered Programs – Allowability & Eligibility Corrective Action Plan: The Refugee Resettlement Program has requested eligibility system changes to prevent eligibility errors. In addition, the Refugee Resettlement Program performs monthly reviews of RMA enrollees and will coordinate case reviews with the RMA team to ensure comprehensive case review. Retraining of eligibility staff will occur as needed. Contact: Sara Bockelman Anticipated Completion Date: April 30, 2026

View Audit 392165

Finding 1179702 (2025-024)

Material Weakness 2025

State of Nebraska

NE

Questioned Costs Subrecipient Monitoring Reporting § 200.511

Program: AL 84.425U – COVID-19 Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief Fund (ARP ESSER) – Reporting Corrective Action Plan: The NDE is in the process of reviewing all FFATA rules and regulations. Within the next three months business rul...

Program: AL 84.425U – COVID-19 Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief Fund (ARP ESSER) – Reporting Corrective Action Plan: The NDE is in the process of reviewing all FFATA rules and regulations. Within the next three months business rules will be established to ensure all federal regulations are being followed when reporting FFATA on a monthly basis. We will have our FFATA Specialist make the corrections in the SAM.gov system to ensure this subaward is reported. This will occur in the next two weeks. As we continue to establish the FFATA procedures we will continue to implement the double checking of all FFATA entries to ensure all funds are reported in the system. Contact: Dottie Heusman, ESEA Assistant Administrator Anticipated Completion Date: June 30, 2026

View Audit 392165

Finding 1179700 (2025-022)

Material Weakness 2025

State of Nebraska

NE

Questioned Costs Cash Management Reporting § 200.102 § 200.207 § 200.302

Program: AL 84.126 – Rehabilitation Services Vocational Rehabilitation Grants to States – Reporting Corrective Action Plan: An additional review will be completed by NDE Budget and Grant Management staff to ensure accuracy. Contact: Cathy Callaway Anticipated Completion Date: Completed

View Audit 392165

Finding 1179689 (2025-001)

Material Weakness 2025

Portland Youthbuilders

OR

Cash Management Questioned Costs Significant Deficiency

2025-001 Finding – Significant Deficiency in Internal Controls over Cash Management Context and Cause – It was noted during the audit that there was not a documented review of the selected cash draws for the program tested. Internal controls should be designed to include a documented supervisory rev...

2025-001 Finding – Significant Deficiency in Internal Controls over Cash Management Context and Cause – It was noted during the audit that there was not a documented review of the selected cash draws for the program tested. Internal controls should be designed to include a documented supervisory review of cash draw requests to ensure accuracy, proper authorization, and compliance with program requirements and the Code of Federal Regulations 200.303. PYB is aware of our Policy for a documented review, but due to competing priorities and impact on workload, the Fiscal Director did not consistently perform the control during the time period that was tested. Auditor Recommendation – Kern & Thompson recommend that PYB re-implement the procedure noted in the prior year, where a supervisor’s initials and date of review was documented on the support for each cash draw, prior to draw down of federal funds. Action Taken – PYB implemented a similar, improved review procedure effective with the October 2025 draw, submitted December 17, 2025. The new procedure uses email to provide documents for review and to document approval of the draw. The Fiscal Director is responsible for submitting cash draws and must send the email to both the Executive Director and the Accountant for review. Each month's emailed documentation includes the DOL income statement for the month (showing the amount for reimbursement); a confirmation that supporting documentation has been attached to the draw request; and a draw confirmation confirming the date of submission, the amount, the date funds should be deposited to PYB’s account, and the justification required for the payment. The Fiscal Director also includes information about the amount of funds remaining on the grant award. After reviewing the documents, the Executive Director replies with approval.

View Audit 392159

Finding 1179682 (2025-001)

Material Weakness 2025

Westfield State University

MA

Student Financial Aid Questioned Costs Reporting

Finding number: 2025-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.007, 84.063, 84.268 Award year: 2025 The Registrar’s Office will perform a mandatory “Missing SSN Report” that picks up missing and invalid SSNs before every ...

Finding number: 2025-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.007, 84.063, 84.268 Award year: 2025 The Registrar’s Office will perform a mandatory “Missing SSN Report” that picks up missing and invalid SSNs before every enrollment data submission to the National Student Clearinghouse (“NSC”). The Registrar will send the Financial Aid Office a list of students with missing SSNs and Financial Aid will verify if students in the report have a FAFSA on file. If there is a FAFSA on file for a student, Financial Aid will update the SSN in the Banner system and send an email confirmation to the Registrar to confirm all records on the report have been reviewed and/or updated. The next enrollment file submitted to the NSC will include the students with the correct data. Furthermore, the Registrar Office will send a written communication to the Provost/Vice President for Academic Affairs verifying that all student records sent the National Student Clearing House has a SSN number prior to any reporting deadline. This communication will be kept on file and available for review for the next audit period. As an additional step, when Financial Aid staff load initially unmatched ISIRs to active Westfield State student records, Banner is now set to automatically populate the student record with the social security number from the matched FAFSA. The goal is to reduce the number of missing social security numbers pulled by the Registrar when they run the “Missing SSN report.” Timeline for Implementation of Corrective Action Plan: Above corrections were implemented in November 2025. Contact Person: Monique Lopez, Registrar and Simone Backstedt, Director, Financial Aid

View Audit 392105

Finding 1179679 (2025-002)

Material Weakness 2025

The Methodist University, Inc.

NC

Special Tests & Provisions Questioned Costs Student Financial Aid

FINDING 2025-002 Name of Responsible Individual: Mary Mercer, Director Student Financial Services Corrective Action: Issue: The current refund report used to monitor Title IV refunds has limitations that affected the completeness of data reviewed. Reports rely on manual batch postings, which can del...

FINDING 2025-002 Name of Responsible Individual: Mary Mercer, Director Student Financial Services Corrective Action: Issue: The current refund report used to monitor Title IV refunds has limitations that affected the completeness of data reviewed. Reports rely on manual batch postings, which can delay or omit certain transactions at the time of report generation. This created gaps in monitoring and potential human error. Action Step Responsible Party Timeline Transition to new system – Implement refund reporting to reduce manual errors and improve completeness. Student Financial Services & IT (if needed) Full adoption by Academic Year 2026–2027 Staff training – Provide comprehensive training to Student Financial Services staff on new system processes, reporting, and controls for Title-IV refunding. Ellucian Consultant & Student Financial Services When training session is scheduled through first report in 2026-2027 Interim verification controls – Conduct weekly reconciliation of batch postings and verifications that all Title IV refunds are captured until the new system is fully operational. Student Financial Services & Controller’s Office Immediate until system adoption Validation & reconciliation process – Establish a formal process within the new system to ensure all refunds are accurately captured and reported. Student Financial Services By first full report in 2026–2027

View Audit 392102

Finding 1179677 (2025-002)

Material Weakness 2025

Granville County, North Carolina

NC

Eligibility Internal Control / Segregation of Duties Questioned Costs

For the Year Ended June 30, 2025 Corrective Action Plan Finding 2025-002 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed completion date: Corrective actions for Finding 2025-005 also apply to State Award findings. Section IV - State Award Findings and Questioned Cost...

For the Year Ended June 30, 2025 Corrective Action Plan Finding 2025-002 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed completion date: Corrective actions for Finding 2025-005 also apply to State Award findings. Section IV - State Award Findings and Questioned Costs Taylor White and Michelle Ogle - Medicaid Supervisors Family and Children Leadership Training: On October 29, 2025, staff received training on self-employment income calculations, including guidance on interpreting tax forms. This training ensures caseworkers correctly document and budget income in the case files going forward. Adult Medicaid Leadership Training: On June 6, 2025, Adult Medicaid leadership conducted SSI Ex Parte training to reinforce policy requirements and timeliness standards for processing program changes. A follow-up SSI training was also held on July 15, 2025, to emphasize the importance of timeliness and policy compliance. Policy and Process Improvement Training: On December 18, 2025, Family and Children Leadership will conduct training on “Noncompliance with Program Requirements and Inadequate Requests,” focusing on online verification review procedures, appropriate notice requirements for undocumented aliens, and appropriate policy sections. This session will include time management training and the implementation of a timeliness checklist to improve case processing efficiency. Adult Medicaid Policy Training: By December 31, 2025, Adult Medicaid Leadership will conduct training covering appropriate policy sections including - Financial Resources verifications, income limit reduction rules, and Transfer of Assets verifications. Adult Medicaid caseworkers will also complete some online trainings and update the review documentation template to include the income limit reduction rules. These corrective actions are designed to strengthen staff knowledge of policy requirements, improve documentation accuracy, and ensure ongoing compliance with timeliness and program standards. All trainings and documentation updates will be completed by December 31, 2025. Section III - Federal Award Findings and Questioned Costs 159

View Audit 392096

Finding 1179676 (2025-006)

Material Weakness 2025

Community Action Partnership of Sonoma County

CA

Equipment & Real Property Management Questioned Costs § 200.313

Finding 2025-006 e. Program Name: Head Start and Early Head Start f. Criteria or Specific Requirement: Physical Inventory Observation: Under 2 CFR 200 200.313(4)(2), a physical inventory of property must be taken at least once every two years. The results should be reconciled with the general ledger...

Finding 2025-006 e. Program Name: Head Start and Early Head Start f. Criteria or Specific Requirement: Physical Inventory Observation: Under 2 CFR 200 200.313(4)(2), a physical inventory of property must be taken at least once every two years. The results should be reconciled with the general ledger. g. Condition: The Organization has not performed a physical inventory in the last two years. h. Response: Physical inventory is currently underway, at about 50% completion across multiple locations. We estimate this will be completed by the end of the fiscal year.

View Audit 392084

Finding 1179675 (2025-005)

Material Weakness 2025

Community Action Partnership of Sonoma County

CA

Questioned Costs

Finding 2025-005 a. Program Name: Community Services Block Grant (CSBG) b. Criteria or Specific Requirement: Tri-Partite Board Composition: The CSBG Act at 42 USC 9910(b) requires that public organizations administer the CSBG program through a tri-Partite board. c. Condition: Less than 1/3 of the me...

Finding 2025-005 a. Program Name: Community Services Block Grant (CSBG) b. Criteria or Specific Requirement: Tri-Partite Board Composition: The CSBG Act at 42 USC 9910(b) requires that public organizations administer the CSBG program through a tri-Partite board. c. Condition: Less than 1/3 of the members of the board of directors of the Organization were representative of the government sector in accordance with CSBG requirements. d. Response: The Organization onboarded public sector board members, but due to turnover are below its membership number and are now low in low income/lived experience sector representation. The Organization is currently short three board members, all of which would need to provide low-income representation. Recruitment is a standing item at our governance committee meetings, and we have two prospective board members.

View Audit 392084

Finding 1179671 (2025-003)

Material Weakness 2025

Community Action Partnership of Sonoma County

CA

Allowable Costs / Cost Principles Questioned Costs

Finding 2025-003 a. Program Name: Head Start and Early Head Start, Coronavirus State and Local Fiscal Recovery Funds b. Criteria or Specific Requirement: Lack of Supporting Documents: Federal requirements under 2 CFR 200 section 303 state that the Organization must establish and maintain effective i...

Finding 2025-003 a. Program Name: Head Start and Early Head Start, Coronavirus State and Local Fiscal Recovery Funds b. Criteria or Specific Requirement: Lack of Supporting Documents: Federal requirements under 2 CFR 200 section 303 state that the Organization must establish and maintain effective internal control over compliance, including controls to ensure payroll costs are charged to federal awards are supported by adequate documentation. Effective internal controls require maintaining sufficient personnel and payroll records, including executed offer letters, and written documentation of wage or position changes with appropriate approvals, to support payroll expenses charged to the program. c. Condition: During payroll testing, we noted instances in which supporting documentation was not retained for payroll activity including missing signed offer letters and / or written approvals of wage or position changes. d. Response: We have implemented a new procedural checklist that accompanies any staff wage or position change. Within this we have clarified that wage changes must be accompanied by a formal letter that is signed by the employee, and that email communications will not suffice. This should ensure that in the future the official signed letters are collected in the format recommended for each such change.

View Audit 392084

Finding 1179658 (2025-003)

Material Weakness 2025

Rogue Community College

OR

Questioned Costs Reporting Significant Deficiency § 200.303

Finding: 2025-003 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number(s): 93.493 Program Name: Community Project Funding Finding Summary: Uniform Guidance at 2 CFR 200.303 requires nonfederal entities to establish and maintain effective internal control over f...

Finding: 2025-003 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number(s): 93.493 Program Name: Community Project Funding Finding Summary: Uniform Guidance at 2 CFR 200.303 requires nonfederal entities to establish and maintain effective internal control over federal awards that provides reasonable assurance that the entity is managing federal awards in compliance with applicable laws, regulations, and the terms and conditions of the award. Effective internal control includes appropriate independent review of reports to ensure accuracy prior to submission. During our testing over the report submissions for the fiscal year, we noted there was not an independent review completed over the quarterly expenditure report. Responsible Individuals: Michael Pollock, CFO and Debbie Dice, Director, Financial Reporting, Audit/Compliance Corrective Action Plan: There was transition in several of the key roles during the fiscal year, causing the review not to be completed over the quarterly submissions that will be rectified during 2025-26. Internal controls will be updated with the following steps: 1) Quarterly federal expenditure reports will be prepared by the an assigned Accountant II member and reviewed by a the Director of Financial Reporting, Audit and Compliance prior to submission to the granting agency; 2) Obtain evidence of the independent review, including reviewer sign-off and date of review, will be documented and retained with the report submission records; 3) The College will update written internal control procedures governing federal grant reporting to formally incorporate the independent review requirement; and 4) The Director of Financial Reporting, Audit and Compliance will monitor adherence to the review process and ensure that documentation is maintained for audit purposes. Anticipated Completion Date: June 2026

View Audit 392056

Finding 1179657 (2025-002)

Material Weakness 2025

Rogue Community College

OR

Special Tests & Provisions Questioned Costs Student Financial Aid

Finding: 2025-002 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.063, 84.007, 84.268, 84.033 Program Name: Student Financial Assistance Cluster Finding Summary: Institutions that implement an affirmative confirmation process (as described in 34 CFR 668.165 (a)(6)(...

Finding: 2025-002 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.063, 84.007, 84.268, 84.033 Program Name: Student Financial Assistance Cluster Finding Summary: Institutions that implement an affirmative confirmation process (as described in 34 CFR 668.165 (a)(6)(i)) must make this notification to the student or parent no earlier than 30 days before, and no later than 30 days after, crediting the student’s account at the institution with Direct Loan. Institutions that do not implement an affirmative confirmation process must notify a student no earlier than 30 days before, but no later than seven days after, crediting the student’s account and must give the student 30 days (instead of 14) to cancel all or part of the loan. Responsible Individuals: Frankie Everett, Director, Financial Aid Corrective Action Plan: The College implemented a new ERP system in the current year that caused delays in notifying students of their loan disbursements. PowerFAIDS allows documenting the email sent to students in the Communication Log, but a box has to be checked when the email batch is sent. This step was inadvertently missed in several batches so we cannot confirm the email was sent. The Department is working to automate the emails with a college-hired consultant. In the meantime, the Financial Aid Operations Coordinator (Jessica Jones) is double-checking that disbursement emails are going out each week. Anticipated Completion Date: June 2026

View Audit 392056

Finding 1179653 (2025-001)

Material Weakness 2025

Rogue Community College

OR

Special Tests & Provisions Questioned Costs Student Financial Aid

Finding: 2025-001 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.063, and 84.268 Program Name: Student Financial Assistance Cluster Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for accurate report...

Finding: 2025-001 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.063, and 84.268 Program Name: Student Financial Assistance Cluster Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for accurate reporting of a student’s enrollment status and changes in those enrollment statuses, whether they report directly or via a third‐party servicer. The support provided by RCC for the students’ last date of attendance did not agree to the students’ withdrawal that had been submitted to NSLDS. Responsible Individuals: Danielle Crouch, Registrar and Analisa Gifford, Assistant Registrar Corrective Action Plan: During the 2023-2024 academic year, we were utilizing an outdated, homegrown Student Information System (SIS). A previously unidentified flaw in the system’s programming logic caused incorrect withdrawal dates to be populated in the National Student Clearinghouse (NSC) report. For the 2024-2025 academic year, we have transitioned to Jenzabar One, an industry-recognized SIS that includes built-in Enrollment Reporting functionality. To ensure accurate reporting moving forward, we are conducting audits of withdrawal dates at the end of each term. With the implementation of this new system and enhanced audit processes, this issue will be fully mitigated. Rogue Community College has implemented corrective actions to strengthen internal controls and ensure the accurate reporting of student enrollment statuses to the National Student Loan Data System (NSLDS). The College now utilizes withdrawal reports to systematically identify students who have withdrawn from all enrolled courses. These reports are reviewed to verify each student’s official withdrawal date prior to submission to NSLDS. For students who receive non-passing grades, the College reviews and reports the last date of attendance, when applicable, to ensure accurate determination of the student’s withdrawal date. As additional internal control, the College conducts term-end audits of withdrawal dates and last dates of attendance to confirm that enrollment status changes have been reported accurately and in accordance with federal requirements. Any discrepancies identified through this review process are corrected promptly. Additionally, the College utilizes graduation reports to verify that students who have completed all program requirements within their declared major are appropriately reported to NSLDS with an enrollment status of Graduated. Through these enhanced monitoring and verification procedures, Rogue Community College is confident that enrollment status changes are reported accurately and in compliance with the requirements outlined in 34 CFR 690.83(b)(2) and 34 CFR 685.309. Anticipated Completion Date: October 2025

View Audit 392056

Finding 1179649 (2025-001)

Material Weakness 2025

Chaffey Community College District

CA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

The District acknowledges that deficiencies in internal controls over the Return to Title IV calculation process resulted in inaccurate calculations. The District has reviewed the identified calculations and corrected all errors. Return to Title IV policies and procedures will be updated and a stand...

The District acknowledges that deficiencies in internal controls over the Return to Title IV calculation process resulted in inaccurate calculations. The District has reviewed the identified calculations and corrected all errors. Return to Title IV policies and procedures will be updated and a standard process is to be completed for every calculation. The District will implement a mandatory secondary review of all Return to Title IV calculations prior to processing returns or post-withdrawal disbursements.

View Audit 392053

Corrective Action Plans

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