Corrective Action Plans

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Corrective Action Plan: Student Records will ensure that all National Student Clearinghouse data is transmitted to NSLDS for reconciliation in a timely manner and coordinate with student accounts to ensure timely transmission of NSLDS data. Timeline for Implementation: Spring 2027 Contact Person: Pe...
Corrective Action Plan: Student Records will ensure that all National Student Clearinghouse data is transmitted to NSLDS for reconciliation in a timely manner and coordinate with student accounts to ensure timely transmission of NSLDS data. Timeline for Implementation: Spring 2027 Contact Person: Peter Long Registrar & Director of Student Records
Audit Finding: Pursuant to 2 CFR 200.512 Report submission, Army West Point Athletic Association Inc. ("AWPAA") did not submit interim performance reports within 30 days after completion of the reporting period through the term of the agreement. Specifically, the interim performance report for one of...
Audit Finding: Pursuant to 2 CFR 200.512 Report submission, Army West Point Athletic Association Inc. ("AWPAA") did not submit interim performance reports within 30 days after completion of the reporting period through the term of the agreement. Specifically, the interim performance report for one of two quarters selected during the period July 1, 2024 – June 30, 2025 was not submitted within 30 days after completion of the reporting period. Root Cause Analysis: The frequency of the reporting has not consistently aligned with material updates. Deadlines were not strictly monitored. Corrective Action Plan: Monitor Reporting Compliance and track submission of Interim Performance Reports to ensure submission by the due date(s). Estimated Completion Date: June 30, 2026 Point of Contact: Thomas Theodorakis, Athletic Director/CEO
Finding 1201590 (2025-001)
Material Weakness 2025
Management will review and update processes and procedures over reporting and additional training will be provided as needed to ensure accurate grant reporting and compliance.
Management will review and update processes and procedures over reporting and additional training will be provided as needed to ensure accurate grant reporting and compliance.
Finding No.: 2025-003 – Disbursements Reporting Federal Agency: U.S. Department of Education Program Name: Student Financial Assistance Cluster – Pell Grant Program and Federal Direct Loan (FDL) Program ALN Number: 84.063, 84.268 Federal Award Year: July 1, 2024 – June 30, 2025 Criteria Institutions...
Finding No.: 2025-003 – Disbursements Reporting Federal Agency: U.S. Department of Education Program Name: Student Financial Assistance Cluster – Pell Grant Program and Federal Direct Loan (FDL) Program ALN Number: 84.063, 84.268 Federal Award Year: July 1, 2024 – June 30, 2025 Criteria Institutions submit Direct Loan, Pell Grant, TEACH Grant, and IASG origination records and disbursement records to the COD system. Origination records can be sent well in advance of any disbursements, as early as the institution chooses to submit them for any student the institution reasonably believes will be eligible for a payment. An institution follows up with a disbursement record for that student no earlier than (1) seven calendar days prior to the disbursement date under the Advance or Heightened Cash Monitoring 1 payment methods, or (2) the date of the disbursement under the Reimbursement or Heightened Cash Monitoring 2 Payment Method. The disbursement record reports the actual disbursement date and the amount of the disbursement. ED processes origination and/or disbursement records and returns acknowledgments to the institution. The acknowledgments identify the processing status of each record: Rejected, Accepted with Corrections, or Accepted. In testing the origination and disbursement data, the auditor should be most concerned with the data ED has categorized as accepted or accepted with corrections. Institutions must report student disbursement data within 15 calendar days after the institution makes a disbursement or becomes aware of the need to make an adjustment to previously reported student disbursement data or expected student disbursement data. Institutions may do this by reporting once every 15 calendar days, bi-weekly or weekly, or may set up their own system to ensure that changes are reported in a timely manner. Title 2 U.S. Code of Federal Regulations Part 200 (2CFR 200) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, section 303(a) states, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statues, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Conditions Found For two (2) out of 69 Pell COD Reports selected for test work, the required Pell student payment data was reported to the Common Origination and Disbursement (COD) website 52 days after disbursement, which exceeds the 15-day timeframe required by federal regulations. For one (1) out of 69 Pell COD Reports selected for test work, the required Pell student payment data was reported to the Common Origination and Disbursement (COD) website 261 days after disbursement, which exceeds the 15-day timeframe required by federal regulations. For four (4) out of 69 Pell COD Reports and three (3) out of 113 FDL COD Reports selected for test work, the Cost of Attendance was misreported to the COD website. There was no follow-up by the University to correct the discrepancies. For ten (10) out of 69 Pell and ten (10) out of 113 FDL COD Reports selected for test work, the transaction number did not agree between the FASFA Submission Summary Form and the COD website. Cause The cause of the conditions found is insufficient review to ensure that accurate disbursement reporting is occurring on a timely basis, all records submitted to COD were accepted, and, for those that were rejected, that corrected data is submitted within the required timeframe. Possible Asserted Effect The possible effect of the condition found is that the University may not be reporting Pell and FDL disbursements to COD completely, accurately, and in a timely manner. Questioned Costs No questioned costs were identified. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes; 2024-002 Views of Responsible Officials Management accepts this finding and notes several issues that affected the submissions including staffing onboarding and training, submission review, and deadline controls. Management continues to fill positions experiencing unexpected turnover and to improve training for current and newly hired staff in order to restore adequate staffing levels and ensure continuity of COD reporting responsibilities. From May through September 2025, management retained Blue Icon Advisors (BIA) to provide dedicated coaching and support for improved onboarding and compliance knowledge, including providing specialized training to the Loan Manager relative to federal regulations and proper loan record management. Management is implementing processes to improve the weekly review and update of Cost of Attendance (COA) information and CPS transaction numbers to further ensure institutional records are aligned with COD data and to reduce the risk of mismatched records. Management has also strengthened internal controls with improvements to processes which enhance the monitoring of submission deadlines, review of file acceptance reports, and identification and correction of electronic records issues prior to submission. These improvements include the increased and more effective utilization of COD-delivered reports (including Pell Reconciliation and Anticipated Disbursement Reports) and institutional and PeopleSoft reports and queries, with reviews conducted on a weekly basis to promptly identify record discrepancies requiring resolution. Anticipated Completion Date March 2026 - completed Responsible Person Nicole Adner, Director of Financial Aid
Audit Finding Reference: 2025-002 Improve Internal Controls and Compliance with Reporting Requirements Planned Corrective Action: BDCC has established a centralized compliance calendar with automated alerts to ensure all Department of Labor (DOL) financial and performance reports are submitted withi...
Audit Finding Reference: 2025-002 Improve Internal Controls and Compliance with Reporting Requirements Planned Corrective Action: BDCC has established a centralized compliance calendar with automated alerts to ensure all Department of Labor (DOL) financial and performance reports are submitted within the required 45-day window. BDCC has implemented a mandatory secondary review for all quarterly reports. Before submission, the Director of Finance & Grant Management will perform a formal reconciliation of report data against the underlying general ledger to ensure accuracy and alignment with federal reporting standards. Planned Implementation Date of Corrective Action: April 1, 2026 Person Responsible for Corrective Action: Joshua Pacheco, Controller
Views of Responsive Officials and Planned Corrective Action: In the future, on all projects involving the use of federal funding, the City will pay careful attention to projects with multiple funding sources to ensure that all funds are accounted for by source to ensure accurate source allocation an...
Views of Responsive Officials and Planned Corrective Action: In the future, on all projects involving the use of federal funding, the City will pay careful attention to projects with multiple funding sources to ensure that all funds are accounted for by source to ensure accurate source allocation and accounting.
Finding 2025-002 - U.S. Department of Education (ED), Title IV Student Financial Aid Programs - Federal Work-Study Community Service Requirement Not Met and Failure to Report FWS Earnings (significant deficiency): Criteria – Per 34 CFR § 675.18(g), each institution participating in the Federal Work-...
Finding 2025-002 - U.S. Department of Education (ED), Title IV Student Financial Aid Programs - Federal Work-Study Community Service Requirement Not Met and Failure to Report FWS Earnings (significant deficiency): Criteria – Per 34 CFR § 675.18(g), each institution participating in the Federal Work-Study (FWS) Program must use at least 7 percent of its total FWS allocation to compensate students employed in community service activities unless the institution has received an approved waiver from the Department of Education. Per 34 CFR § 675.19(b), institution must maintain fiscal control and accountability over FWS funds and comply with all reporting requirements established by the Secretary. This includes accurately reporting FWS student earnings through required federal systems and maintaining documentation to support reported activity. Condition - Based on documentation provided for the 2024–2025 award year, the institution was authorized a total of $26,649 in Federal Work-Study funds. Of this amount, only $1,057 was identified as wages paid to students employed in community service activities. No documentation was provided to demonstrate that additional community service wages were paid or that a waiver from the U.S. Department of Education of not meeting the required 7 percent community service expenditure threshold. Additionally, during review of the institution’s 2024–2025 Federal Work-Study (FWS) activity, it was noted that FWS student earnings were not reported to the Common Origination and Disbursement (COD) System. The institution’s financial aid records and payroll registers indicate that students earned a total of $23,131 in FWS wages during the award year; however, no corresponding COD submissions or COD acknowledgment files were provided for review to demonstrate that these earnings were reported as required. Cause – The infraction appears to have resulted from failure to monitor compliance with the 7 percent FWS community service requirement and inadequate internal controls to ensure timely and accurate reporting of FWS earnings. Effect – The institution did not comply with the statutory community service spending requirement and FWS earnings were not reported through required federal reporting channels, limiting transparency and federal oversight. Questioned Costs - $0 Perspective – The Federal Work-Study Program includes explicit statutory spending and reporting requirements that are considered key compliance controls. In this instance, the institution expended approximately 4 percent of its authorized FWS allocation ($1,057 of $26,649) on community service wages, compared to the required 7 percent, resulting in a 43 percent shortfall from the required threshold. In addition, 100 percent of FWS earnings identified during testing ($23,131) were not reported to the COD System, as no submission or acknowledgment records were available. Repeat Finding – No Auditor’s Recommendation – We recommend that the institution strengthen monitoring of community service requirements and establish formal FWS reporting controls and perform periodic internal audits of FWS expenditures and reporting to identify and correct issues prior to year-end and federal reporting deadlines. Management’s Response – Per 34 CFR § 675.18(g), each institution participating in the Federal Work-Study (FWS) Program must use at least 7 percent of its total FWS allocation to compensate students employed in community service activities. Based on documentation provided for the 2024-2025 award year, the institution was authorized a total of $26,649 in Federal Work-Study funds. Of this amount, $1,057 was identified as community service wages. No documentation was provided to demonstrate that additional community service wages were paid or that a waiver from ED was requested or approved
Information on the federal program: Federal Direct Student Loans, FAL No. 84.268, June 30, 2025; Federal Pell Grant Program, FAL No. 84. 063, June 30, 2025; Federal Supplemental Educational Opportunity Grant, FAL No. 84.007, June 30, 2025; Federal Work-Study Program, FAL No. 84.033, June 30, 2025. F...
Information on the federal program: Federal Direct Student Loans, FAL No. 84.268, June 30, 2025; Federal Pell Grant Program, FAL No. 84. 063, June 30, 2025; Federal Supplemental Educational Opportunity Grant, FAL No. 84.007, June 30, 2025; Federal Work-Study Program, FAL No. 84.033, June 30, 2025. Finding 2025-001 - U.S. Department of Education (ED), Title IV Student Financial Aid Programs- Pell Grant Disbursement Reported in Incorrect Award Year (significant deficiency): Criteria – Per 34 CFR § 690.61, institutions must ensure that Pell Grant disbursements are made and reported for the correct award year and in accordance with program requirements. Institutions are required to report Pell Grant disbursements in the correct award year and submit all disbursement records by the published COD closeout deadline for the applicable award year Disbursements not reported by the closeout deadline may not be shifted to a subsequent award year to compensate for missed reporting. Condition - For the 2024–2025 award year, testing revealed that one (1) out of ten (10) students selected for testing became eligible for a Federal Pell Grant disbursement of $204 during the 2023–2024 award year. The institution failed to process and report the disbursement in COD prior to the 2023–2024 COD closeout deadline. To compensate, the institution incorrectly posted the $204 disbursement to the student’s account and reported the payment to COD under the subsequent 2024–2025 award year. Cause – The infraction appears to have resulted from failure to monitor and comply with COD Pell Grant closeout deadlines and inadequate controls to ensure disbursements are reported in the correct award year. Effect – Pell Grant disbursement activity was reported inaccurately to the Department of Education. Reporting the disbursement in the incorrect award year compromises the accuracy and integrity of federal Pell reporting. Misreported Pell activity increases the risk of required data corrections and program review findings. Questioned Costs - $204 Perspective – Accurate and timely reporting of Pell Grant disbursements by award year is a key Title IV compliance control, as Pell Grant funding is awarded, monitored, and closed out on an annual basis. In this instance, one (1) out of ten (10) students tested (10%) had a Pell Grant disbursement that was reported in an incorrect award year due to failure to meet the applicable COD closeout deadline. Although the dollar amount involved was limited, the error demonstrates that controls designed to ensure award-year accuracy and timely COD reporting did not operate effectively. Repeat Finding – No Auditor’s Recommendation – We recommend that the institution strengthen closeout monitoring procedures, ensure award-year accuracy, and perform periodic internal reviews. Management’s Response – For the 2024–2025 award year, one (1) out of ten (10) students selected for testing became eligible for a Federal Pell Grant disbursement of $204 in the 2023-2024 award year. The institution failed to process the disbursement in COD prior to the 2023-2024 closeout deadline. To compensate, the institution incorrectly posted the $204 disbursement to the student’s account and reported the payment to COD under the subsequent 2024-2025 award year. Per 34 C.F.R. § 690.61 and the U.S. Department of Education’s Common Origination and Disbursement (COD) system requirements, institutions must report Pell Grant disbursements in the correct award year and by the published COD closeout deadline. A. Agree B. Conditions That Caused the Infraction a. Upon further review of the student’s account ledger, the institution identified that a $204 Pell Grant disbursement was incorrectly reflected for the Fall 2024 term. The student did not attend or enroll in Fall 2024; therefore, no Title IV funds should have been associated with that payment period. b. The Pell award was disbursed but was not properly aligned with the student’s actual enrollment timeline. Although the student attended Summer 2024 and Spring 2025, the institution did not submit a Student Bill Letter (SBL) for Spring 2025 because the student was enrolled in only one course. At the time, institutional practice did not require SBL submission for students enrolled less than half time or in a single course. As a result:  The Pell disbursement was not aligned with the correct payment period.  The $204 Pell award was incorrectly reflected as a Fall 2024 disbursement instead of being applied to the appropriate term.  This created a compliance issue related to Title IV disbursement timing and documentation.  Subsequent guidance from FA Solutions clarified that SBLs must be submitted for all enrolled students, regardless of enrollment intensity, to ensure proper alignment of Title IV funds with the correct payment period. C. The School’s Planned Corrective Action Plan (CAP)- The institution will implement the following corrective actions to address and prevent recurrence of this finding: a. Ledger Correction  The Student Accounts Office will revise the student’s ledger to accurately reflect the $204 Pell Grant disbursement as a Summer 2024 credit/refund, the term in which the student had eligible enrollment.  Any misapplied term references will be removed to ensure alignment with Title IV regulations. b. Policy and Procedure Update  Institutional procedures will be updated to require submission of Student Bill Letters (SBLs) for all enrolled students, including those enrolled in a single course or less than half time, when Title IV funds are involved.  This requirement will be documented in both Financial Aid and Student Accounts procedural manuals. c. Staff Training  Financial Aid and Student Accounts staff will receive training on updated SBL submission requirements and Title IV disbursement alignment.  Training will include review of payment period eligibility, enrollment intensity, and documentation standards. d. Cross Departmental Review Process  Financial Aid and Student Accounts will implement a secondary review process prior to Pell disbursement to confirm:  Enrollment for the applicable term  Presence of a submitted SBL  Correct payment period assignment D. Responsible Officials a. Dr. Gina Garlington, Financial Aid Administrator Responsible for Title IV compliance, staff training, SBL submission, and oversight of Pell disbursement procedures. b. CLA, Third Party Servicer and School’s Student Accounts Office Responsible for ledger corrections, and reconciliation of student accounts. E. Expected Timeline for Implementation a. All timelines have been complete F. Monitoring of Corrective Action Plan a. The CAP will be monitored through the following mechanisms:  Monthly reconciliation reviews between Financial Aid and Student Accounts  Random sampling of Pell disbursements to confirm correct payment period alignment.  Annual internal compliance review of SBL submissions and Title IV disbursements.  Documentation of corrective actions retained for audit and program review purposes.  Any discrepancies identified during monitoring will be addressed immediately and documented. G. Status of CAP Prior to This Finding a. This is the first occurrence of this finding for the institution. b. No prior corrective action plan existed addressing this specific issue. View of Responsible Officials- Officials agree with findings
Management agrees with this finding. The instance in which a Pell Grant disbursement was not reported to the U.S. Department of Education Common Origination and Disbursement (COD) System within the required 15 calendar days was due to the student not answering the high school completion question on ...
Management agrees with this finding. The instance in which a Pell Grant disbursement was not reported to the U.S. Department of Education Common Origination and Disbursement (COD) System within the required 15 calendar days was due to the student not answering the high school completion question on the Free Application for Federal Student Aid (FAFSA), which relates to Ability to Benefit (ATB) eligibility. To address this issue and prevent recurrence, we have implemented an additional control. We now identify students who have been awarded a Pell Grant but have not answered the FAFSA high school completion question. For these students, an ATB requirement is posted on RRAAREQ, which prevents the Pell Grant from disbursing until the FAFSA question has been resolved. This process change ensures that Pell Grant funds will not disburse until the FAFSA high school completion question is completed, allowing the Pell Grant record to successfully extract to COD within the required reporting timeframe. This system update corrects the condition identified in the audit finding and strengthens our internal controls to ensure compliance with federal reporting requirements.
Establish a formal reconciliation process between the general ledger and amounts reported in the FISAP; require documented review and approval of all FISAP data by the Controller or CFO prior to submission; Enhance the year-end closing timeline to ensure all relevant financial data is finalized befo...
Establish a formal reconciliation process between the general ledger and amounts reported in the FISAP; require documented review and approval of all FISAP data by the Controller or CFO prior to submission; Enhance the year-end closing timeline to ensure all relevant financial data is finalized before FISAP preparation; Develop and maintain written procedures for FISAP prepartion and review to ensure continuity during staffing transitions; Provide cross-training for key personnel involved in federal reporting to mitigate risks associated with turnover
2025-002 Accounts Payable Cutoff We acknowledge BDO’s inquiry regarding an invoice that appeared to relate to the prior fiscal period. The invoice was received after Accounts Payable closed without advance notification for accrual. BDO noted a similar issue in an additional sample. To strengthen our...
2025-002 Accounts Payable Cutoff We acknowledge BDO’s inquiry regarding an invoice that appeared to relate to the prior fiscal period. The invoice was received after Accounts Payable closed without advance notification for accrual. BDO noted a similar issue in an additional sample. To strengthen our accounts payable cutoff controls and prevent similar issues, we will implement the following improvement measures: • Formalize the Accrual Process – While an accrual process already exists, before the end of FY26, we will document and strengthen the accrual procedures by requiring Program Managers to notify Finance, specifically the AP team inbox, when work from a vendor has been completed, but an invoice has not yet been received, on an annual basis by a given deadline. This will ensure that known obligations are captured in the correct fiscal period. • Strengthen Review of Post-Year-End Invoices – While regular review of invoices is already a part of our regular AP process, Accounts Payable will implement a more stringent review process before the end of FY26 for all invoices received in the first period after fiscal year end, including verification of service dates, contract terms, and deliverables. • Enhanced Communication Expectations – Program Managers will receive training and guidance before the end of FY26 on the importance of timely invoice submission and the need to alert Finance when delays occur. • Documentation of Cutoff Decisions – For invoices received after close, before the end of FY26, Accounts Payable will document the receipt date, supporting details, and rationale for the period in which the expense is recorded to maintain a clear audit trail. These improvements will strengthen our internal controls over AP cutoff, improve the consistency of accrual practices, and reduce the risk of misstatements due to late or ambiguous invoices. Responsible Individual: Claire Danielson, VIP of Finance Estimated Completion Date: June 30, 2026
Child Nutrition Cluster, ALN’s 10.553 & 10.555 Recommendation: We recommend the review and approval process over monthly claims for reimbursement be strengthened to enhance the prevention of discrepancies between the claim for reimbursement and underlying data. Explanation of disagreement with audit...
Child Nutrition Cluster, ALN’s 10.553 & 10.555 Recommendation: We recommend the review and approval process over monthly claims for reimbursement be strengthened to enhance the prevention of discrepancies between the claim for reimbursement and underlying data. Explanation of disagreement with audit finding: Management agrees with the finding. Action taken in response to finding: Newton operated the National School Lunch Program (NSLP) during the Extended School Year (ESY) for the first time during the summer 2024, which created a reporting challenge. Students from across the district's 23 schools attended ESY in seven (7) schools/sites, but their school-year home schools could not be changed in the Student Information System (Aspen). Therefore, student meal counts reported to their home school on the FP9 but had to be reported on the DESE School Report for the ESY school/site they attended. Given the system interface complexities, some counts had to be manually entered, for which two (2) meal counts were incorrectly entered for breakfast versus lunch. Given that the district did not operate the School Breakfast Program (SBP) and did not serve breakfast, these two (2) manual errors were counted as lunch counts when entered for the School Report. The total meal count did match on the FP9 and School Report. For this inconsistency, the correct action should have been to manually update these two counts in the Point of Sale system (Mosaic) so that the two breakfast counts reflected correctly as lunch counts. Name(s) of the contact person(s) responsible for corrective action: Amy Mistrot, NPS Director of Business Operations. Planned completion date for corrective action plan: Newton was able to set conditional parameters in Aspen for ESY 2025 so that the student meal counts reported to their ESY school/site versus their home school, so this reporting issue was corrected the following summer.
The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Fi...
The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Finance staff will also create new line items to ensure separation of grants from other special revenue. Additionally, the Town will reflect Retainage Payable on balance sheets. The estimated completion date is June 1, 2026. Jay Hendrix, Town Manager, is responsible for overseeing the corrective action plan and that implementation occurs by the estimated completion date.
The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Fi...
The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Finance staff will also create new line items to ensure separation of grants from other special revenue. Additionally, the Town will reflect Retainage Payable on balance sheets. The estimated completion date is June 1, 2026. Jay Hendrix, Town Manager, is responsible for overseeing the corrective action plan and that implementation occurs by the estimated completion date.
Condition: The District's expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Management will review all expenditure reports. Only expenditures obligated within the grant period wi...
Condition: The District's expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Management will review all expenditure reports. Only expenditures obligated within the grant period will be included on the expenditure report. Any obligations not yet liquidated will be reported as such.
Condition: Multiple individuals are responsible for the preparation and submission of the District's quarterly exepnditure reports; however, the expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of t...
Condition: Multiple individuals are responsible for the preparation and submission of the District's quarterly exepnditure reports; however, the expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Mannagement will review all expenditure reports. Only expenditures obligated within the grant period will be included on the expenditure report. Any obligations not yet liquidated will be reported as such.
Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. ...
Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. Additionally, ongoing training should be provided to financial aid staff on the importance of internal controls and compliance with Title IV regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review its staffing and the need for separation of duties as part of an effective internal control system and take appropriate actions.. Name(s) of the contact person(s) responsible for corrective action: Vice President for Enrollment Management Damon Wade, Director of Financial Aid Deniesha Newby, and Controller Will Gibbons Planned completion date for corrective action plan: June 30, 2026
Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreem...
Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that its policies and procedures are reviewed and updated to ensure compliance with this recommendation. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby Planned completion date for corrective action plan: June 30, 2026
National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with au...
National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review regulations to ensure that staff understands reporting requirements of the NSLDS. Name(s) of the contact person(s) responsible for corrective action: Financial Aid Director Deniesha Newby Planned completion date for corrective action plan: June 30, 2026
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended Se...
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2025 Finding Reference Number: 2025-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of payroll expenditures to support activities allowed or unallowed and allowable costs/cost principles related to payroll expenditures reimbursed for the project worksheet. Corrective Action Plan: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late fiscal year 2022 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: revised the timekeeping policy to clarify employee and manager responsibilities, modified “failure to comply” provisions, deployed educational programs for both management and staff, reviewed/improved Kronos and UKG Pro Time and Attendance system automated notifications, and training resources have been available to management and staff via our Scripps intranet site. Leadership monitors policy compliance by individual employee and managers via systemwide reporting on a biweekly basis. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: Completed in fiscal year 2022. As the expenditures in the project worksheet were incurred from the beginning of the COVID-19 pandemic, the corrective action plan put in place during 2022 could not previously remediate the project; however, all payroll expenditures incurred after the end of fiscal year 2022 have these corrective actions in place.
Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We fou...
Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We found another instance of a student’s information not reported timely, however management did eventually detect and correct the error outside the required timeframe. Corrective Action planned: Management agrees and has implemented necessary procedures/controls to ensure the College is in compliance with enrollment requirements. Management has corrected the student’s change status not previously reported. Name(s) of Contact Person(s) Responsible for Corrective Action: {Jennifer Young, Director of Financial Aid and Edgewood Central, and Katelyn Peters, Student Service Specialist.} Anticipated Completion Date: Has already began as of the audit. Staff turnover occurred, have replaced the Student Service Specialist position - now have second point on NSC reporting.
Finding 1201454 (2025-002)
Material Weakness 2025
Finding: The change in student status for 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) timely when the student withdrew or changed status during the fiscal year. The change in student status for an additional 2 of 25 students tested was not reported to th...
Finding: The change in student status for 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) timely when the student withdrew or changed status during the fiscal year. The change in student status for an additional 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) accurately when the student graduated during the fiscal year. Explanation for Finding: The Registrar's data collection was not reviewed after submission to National Student Clearinghouse (NSC) by another responsible individual to ascertain the accuracy of graduate, withdrawal and status change dates of students being reported. The College received a response from NSC of no errors, therefore the withdrawn student in question was not reported in a timely manner. Corrective Actions Taken or Planned: The Registrar will run a report on the 15th of the month to verify any students that have exited the institution from the prior two submission periods (last two months) have valid exit dates in the National Student Loan Clearinghouse. The Assistant Registrar will review the work of the Registrar and verify any discrepancies between Coe’s records and those stored in the National Student Clearinghouse for correction. The Registrar will then ensure timely and accurate submission of student records from the Clearinghouse to NSLDS after all the data has been reviewed. When there are staffing changes in the future that impact a person on the staff in the Office of the Registrar who has been responsible for the verification and reporting of valid exit dates in the National Student Loan Clearinghouse, it is the responsibility of the Registrar, unless the Registrar has left, in which case it shall be the responsibility of the Assistant Registrar, to appoint another specific staff member in the Office of the Registrar to take the actions required by the written policy for the verification and reporting of this data. Persons Responsible and Completion Date: Registrar, Assistant Registrar. The actions outlined above has been added to the Withdrawal & Exit Procedure (NSC-NSLDS) as of 10/28/2025
Name of Contact Person: Amanda John, Executive Director. Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately.
Name of Contact Person: Amanda John, Executive Director. Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately.
Program: Congressionally Recommended Awards / HOME Investment Partnerships Program / Homeland Security Grant Program / Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 16.753 / 14.239 / 97.067 / 93.323 Federal Grantor: U.S. Department of Justic...
Program: Congressionally Recommended Awards / HOME Investment Partnerships Program / Homeland Security Grant Program / Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 16.753 / 14.239 / 97.067 / 93.323 Federal Grantor: U.S. Department of Justice / U.S. Department of Housing and Urban Development / U.S. Department of Homeland Security / U.S. Department of Health and Human Services Award No. and Year: Multiple Compliance Requirements: Other – Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of expenditures of Federal awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria: Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) states that the auditee (the County) must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements, which must include the total federal awards expended as determined in accordance with §200.502. §200.331 of the Uniform Guidance states the County is responsible for making case-by-case determinations to determine whether the entity receiving the Federal funds is a subrecipient. In addition, §200.303 of the Uniform Guidance states that the County must establish and maintain effective internal control over the federal awards, including controls over the accuracy of program information and expenditure amounts. Condition: During our audit procedures performed over the SEFA we noted the following: • The Sheriff-Coroner Department did not properly identify the amount expended for the Congressionally Recommended Awards, AL No. 16.753. The expenditures reported by the Department were overstated by $2,638,516. • The Orange County Community Resources Department did not properly identify the amount of Federal funding passed through to subrecipients for the HOME Investment Partnerships Program, AL No. 14.239. The amount passed through to subrecipients reported by the Department was overstated by $4,500,624. • The Sheriff-Coroner Department did not properly identify the amounts expended for the Homeland Security Grant Program, AL No. 97.067. The expenditures reported by the Department were overstated by $715,489. • The Orange County Health Care Agency (HCA) did not properly identify the amount expended for the Epidemiology and Laboratory Capacity for Infectious Disease program, AL No. 93.323. The expenditures reported by the Agency were overstated by $486,000. Cause: As a result, the County lacked adequate internal controls to ensure the SEFA is completely and accurately stated. Specifically, the County’s processes for recording and tracking expenditures of Federal awards are not designed so that expenditures are identified when incurred. In addition, the County’s processes for identifying and reporting subrecipients are not designed to ensure appropriate reporting on the SEFA. Effect: Adjustments to the SEFA were required. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. Program expenditures and amounts passed through to subrecipients were reconciled to the supporting records. Repeat Finding from Prior Years: No. Recommendation: The County, including all its reporting departments, should follow existing policies, procedures and internal controls to ensure all expenditures and amounts passed through to subrecipients are accurately tracked and reported on the SEFA. Personnel knowledgeable of federal expenditures should review amounts coded to federal programs for completeness and accuracy. The SEFA should be prepared and reviewed in a timely manner and reconciled to underlying records as well as the basic financial statements. Management Response and Corrective Action Plan: Health Care Agency: 1. Person Responsible: David Santalahti, HCA Claims & Financial Reporting Manager 2. Corrective action plan: HCA Accounting will review and enhance its procedures and training for analysis and tracking federal award expenditures to ensure expenditures are reported in the appropriate fiscal year period. 3. Anticipated Implementation date: June 30, 2026 Orange County Community Resources: 1. Person Responsible: Bill Malohn, OCCR Accounting Manager 2. Corrective action plan: Concur. OCCR has established policies and internal controls to ensure all expenditures and amounts passed through to subrecipients are accurately tracked and reported on the SEFA. Appropriate personnel review amounts coded to federal programs for completeness and accuracy. We prepare and review the SEFA in a timely manner and reconcile to underlying records as well as the basic financial statements. In this particular situation, we miscategorized one provider as a subrecipient and reported the related funding as such on the SEFA. This oversight had no impact on the total amount we reported on the SEFA. We will be sure to follow our policies and procedures to ensure accurate SEFA reporting. 3. Anticipated Implementation date: February 2, 2026 Sheriff-Coroner: 1. Person Responsible: Monique Vansuch, Fiscal Administrator 2. Corrective action plan: The Sheriff-Coroner Department acknowledges the finding and recognized federal grant expenditure incurred is defined as when expenditures are delivered and/or services are performed rather than when the expenditures are paid. We will strengthen the internal controls to ensure grant expenditures are reported per the Uniform Guidance. 3. Anticipated Implementation date: June 30, 2026
Program: Housing Voucher Cluster Federal Financial Assistance Listing Number: 14.871 / 14.879 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: Multiple Compliance Requirements: Special Tests and Provisions – HQS Enforcement Type of Finding: Significant Deficiency...
Program: Housing Voucher Cluster Federal Financial Assistance Listing Number: 14.871 / 14.879 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: Multiple Compliance Requirements: Special Tests and Provisions – HQS Enforcement Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: The 2025 OMB Compliance Supplement requires that for dwellings under Housing Assistance Payment (HAP) contracts that fail a Housing Quality Standards (HQS) inspection, the County must enforce HQS requirements. Specifically, upon notification that a unit has failed HQS, the County must inspect the unit within 15 days to confirm the deficiency and notify the owner if the deficiency is confirmed. Once notified, the owner is required to make the necessary repairs within the prescribed time frame. If the owner does not correct the cited HQS deficiencies within the specified correction period, the County must stop (abate) HAPs beginning no later than the first of the month following the specified correction period or must terminate the HAP contract. Condition: For one sample selected for testing, the County did not timely enforce HQS requirements. Cause: The cause of the finding was an administrative oversight that resulted in delays in issuing the final inspection notice following a missed inspection appointment. The County’s existing procedures did not adequately ensure timely follow-up and escalation when an inspection resulted in a noshow. Effect: Because the required inspection and notification were not completed timely, the County did not fully comply with the HQS enforcement requirements. This delay increased the risk that housing assistance payments could continue for a unit that did not meet HUD’s minimum housing quality standards, potentially affecting program compliance and participant health and safety. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of sixty (60) out of a total population of 1,029 instances of failed HQS were selected. The condition noted above was identified during our procedures related to special tests and provisions – HQS enforcement. Repeat Finding from Prior Years: No. Recommendation: We recommend the County strengthen its HQS enforcement procedures by implementing controls to ensure timely follow-up on failed inspections, including missed appointments. Such controls may include automated tracking of inspection deadlines, supervisory review of no-show appointments, and escalation procedures to ensure owners are notified within required time frames. Management Response and Corrective Action Plan: 1. Person Responsible: Linda Tarzjani, Leasing Manager 2. Corrective action plan: Concur. We will strengthen our HQS enforcement procedures by implementing controls to ensure timely follow-up on failed inspections, including missed appointments. In doing so we will consider automated tracking of inspection deadlines, supervisory review of noshow appointments, and escalation procedures to ensure owners are notified within required time frames. 3. Anticipated Implementation date: February 1, 2026
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