Corrective Action Plans

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Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for a...
Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for all journal entries made to the program to ensure that amount charged to the program are actual expenses/expenditure of the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Goi...
Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Going forward, the Organization will review all vouchers being charged to the program to make sure costs have been incurred before being charged to the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025
View Audit 351890 Questioned Costs: $1
Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating...
Reporting - FSRS Block Grants for Prevention & Treatment of Substance Abuse - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS s...
Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to ...
Reporting - FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: Complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: April 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization con...
Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us...
Finding 2024-003: Allowable Costs – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, and oversight. These will include: • Departments will ensure that all expenses are reviewed to confirm alignment with the specific terms and conditions of the grant before reallocating any charges. • Redistribution of Award expenses will be reviewed and approved by Division Director and/or Finance Grant Manager • Federal Awards quarterly reporting will be reviewed and approved by Finance Grant Manager prior to submission • Journal Entries will be for correcting entries and not move funded expenditures to other funding revenues • All Journal Entries will have complete supporting documentation reviewed and signed by Director level staff at the Division or by Finance Grant Management Anticipated Completion Date: Implementation of controls by March 24, 2025.
Finding 2024-001: Reporting – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-9...
Finding 2024-001: Reporting – Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Management agrees with the finding and the auditor’s recommendation. Contact Person responsible for corrective action: Elizabeth Comfort Finance Director ecomfort@clackamas.us 503-936-5345 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, oversight, and record retention related to reporting of subawards greater or equal to $30,000. These will include: • Timely monitoring for the status of FFATA subaward reporting • Receive the FFATA subaward report to SAM.gov confirmation from Sub Recipient contractor • Retain documentation of submission to SAM.gov • Include quarterly cash-on-hand reports to award checklist to be completed in the Finance office • Compile listing of current open subrecipient agreements for adherence to FFATA contractor award reporting to ensure compliance Anticipated Completion Date: Implemented as a control to the Finance Grant checklist for each award March 20, 2025.
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive...
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure accurate preparation and submission of financial reports within the required timeframe. Implementation Date: April 1, 2025. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director
View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting ...
View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder and the funder will not seek to recoup out of period costs. Moving forward, the Organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest an...
CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest and Procurement procedures. Conflict-of-Interest and procurement policy training sessions were conducted with all levels of staff and will continue to be conducted on a recurring basis. CCS is implementing additional layers of oversight and compliance monitoring. This is the responsibility of the CCS Chief Financial Officer. CCS is committed to continuous improvement, conducting regular internal audits and reviews to verify adherence to federal procurement standards. This is the responsibility of the CCS Revenue Cycle Manager. We are working to ensure that every vendor has a contract on file and all procurement policies are strictly followed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.
Finding 547917 (2024-003)
Significant Deficiency 2024
2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set f...
2024-003 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Condition: The College did not report student enrollment data to the National Student Clearinghouse within the minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR Section 685.309(b)(2), the College is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The College does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Context: From a population of 26 students that withdrew officially and unofficially during a term, we tested 3 students and noted those students’ withdrawals were not reported timely or accurately. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Recommendation: We recommend that a review process be put in place to ensure timely and accurate enrollment reporting to NSLDS and additional training on the reporting requirements as needed. Management Response: Management is working with the Registrar’s Office to determine why there was an issue and provide a process that will eliminate any untimely reporting to Clearinghouse moving forward. If the Federal Audit Clearinghouse has questions regarding this plan, please call Angie Edmondson, CFO, 276-944-6755, aedmonds@emoryhenry.edu
Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students ...
Identification and Review • Conduct an internal audit to identify all students who failed all courses and determine the last date of attendance for each. • Review institutional records (For example, faculty attendance records, Learning Management or participation records) to establish when students stopped engaging academically • Verify whether R2T4 calculations should have been performed Corrective Actions • Process R2T4 calculations for affected students based on their last date of attendance • Return any unearned Title IV funds • Update students file to reflect accurate withdrawal dates and notify them of any financial obligations resulting from the adjustment • If students are still enrolled in future terms, ensure they understand satisfactory academic progress (SAP) implications Process and Policy Improvements • Implement an early alert system to identify students who cease attendance before the end of the term. • Strengthen collaboration between academic departments, the registrar, and the financial aid office to improve withdrawal tracking • Run monthly withdrawal reports to see when students earn all failing grades. Monitoring and Compliance • Conduct regular audits to ensure compliance with R2T4 regulations and timely student withdrawals • Provide staff training on withdrawal procedures and the importance of accurately tracking last dates of attendance. • Establish a set time to review withdrawal policies and ensure adherence to federal regulations. Reporting and Documentation • Maintain detailed records of all identified cases, R2T4 calculations, and funds returned. • Document all policy and procedural updates made to prevent recurrence. • If required, submit a report to the U.S. Department of Education outlining corrective actions taken. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25
View Audit 351835 Questioned Costs: $1
Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting d...
Identification and Review • Conduct a comprehensive audit of enrollment records to identify instances of inaccurate or delayed reporting • Verify the accuracy of enrollment statuses (e.g., full-time, half-time, withdrawn, graduated) for all affected students • Determine the root cause of reporting delays or errors, whether due to system malfunctions, manual processing errors, or lack of oversight Corrective Actions • Submit corrected enrollment data to NSLDS for all affected students using our National Student Clearinghouse. • Ensure that all errors identified during the audit are addressed, and follow up to confirm the corrections are reflected in NSLDS. • Notify any impacted students of any changes in their enrollment status and provide necessary support if their loan repayment terms are affected. Process and Policy Improvements • Develop and implement clear policies to ensure accurate and timely submission of enrollment data within the required 30-day reporting window or in accordance with scheduled reporting intervals. • Automate the enrollment reporting process where possible to minimize manual data entry errors. • Establish cross-departmental communication protocols to ensure timely updates on student withdrawals, graduations, and status changes. • Create detailed documentation of reporting procedures for staff training and compliance purposes. Monitoring and Compliance • Implement regular reconciliation checks between our student information system (SIS) and NSLDS to ensure data accuracy • Conduct periodic internal audits to identify discrepancies before external audits occur • Designate staff to oversee enrollment reporting and ensure adherence to federal regulations. Staff Training • Provide comprehensive training for staff responsible for enrollment reporting on NSLDS requirements, deadlines, and best practices • Offer training sessions as regulations change or system updates occur. Reporting and Documentation • Maintain records of all corrected data submissions, audit results, and communications with NSLDS • Document procedural changes and staff training efforts Responsible Person for Correction Action Plan: Dianna Ruyle, Director of Records, Registration and Advising Implementation Date for Corrective Action Plan: Immediately and ongoing
FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a re...
FINDING 2024-004 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submitted timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control sur...
FINDING 2024-003 – Reporting; Significant Deficiency in Internal Control over Compliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all financial reports, special reports, and performance reports. Reports required by contract must be submited timely and must have two levels of documented review. All financial reports required by contract must have a documented review by a member of the fiscal department. Additionally, report backup and proof of timely submission must be retained. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller
2024-011 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 Compliance Requireme...
2024-011 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 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: In accordance with the 2024 OMB Compliance Supplement, nonfederal entities must record expenditures on the Schedule of Expenditures of Federal Awards (SEFA) when (1) FEMA has approved the nonfederal entity’s Project, and (2) the nonfederal entity has incurred the eligible expenditures. FEMA’s approval of a subaward is indicated when FEMA obligates the federal share of the eligible project cost to the recipient. Federal awards expended in years subsequent to the fiscal year in which the Project is approved are to be recorded on the nonfederal entity’s SEFA in those subsequent years. In addition, section 200.303 of the Uniform Guidance states that recipients and subrecipients must establish 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 Schedule of Expenditures of Federal Awards and expenditures reported for the Disaster Grants – Public Assistance (Presidentially Declared Disasters) we noted the County reported expenditures totaling $5,820,436 that should have been reported on the FY 2023 SEFA, as the granting agency approved the expenditures in FY 2023 and the County incurred the expenditures prior to June 30, 2023. Cause: The County lacks adequate internal controls to ensure the SEFA is completely and accurately stated. Effect: The initial FY 2024 SEFA provided was overstated by $5,820,436. However, we noted these expenditures would not have had a material effect on the FY 2023 SEFA. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. Program expenditures on the SEFA were reconciled to supporting records. Repeat Finding from Prior Years: No. Recommendation: We the recommend that the County establish policies and implement internal controls to ensure that expenditures are reported on the SEFA in accordance with program requirements. Management Response and Corrective Action: 1. Person Responsible: Trevor Richardson, OCPW Emergency Manager 2. Corrective Action Plan: Due to the change in reporting guidance, we will now report the full amount of the award in the fiscal year it is approved, based on the obligation letter, instead of on a cash basis. 3. Anticipated Implementation date: Effective immediately for FY24-25.
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance ...
2024-010 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 and 2019 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that 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 statutes, regulations, and the terms and conditions of the Federal award. Condition: For two (2) out of three (3) project application summary reports tested, the OCPW did not retain evidence to document the individual who reviewed and approved the required reports. Cause: The department’s procedures did not include documenting the review and approval of the reports prior to submission. Effect: Ineffective controls over this area of compliance could result in reports that are inaccurate or incomplete being submitted or disclosed to the granting agency. Questioned Costs: No questioned costs were identified as a result of our audit procedures. Context/Sampling: A non-statistical sample of three (3) of nine (9) Grant Project Application Summary Reports were selecting for testing. The condition above was identified during our procedures over reporting testing. Repeat Finding: No. Recommendation: We recommend the OCPW department revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. Management Response and Corrective Action: 1. Person Responsible: • FEMA Public Assistance Grants Coordinator – Responsible for completing reports, uploading documents to the FEMA Grants Portal, and ensuring accurate records. • OCPW Emergency Manager Responsible for reviewing, approving, and submitting project applications. 2. Corrective Action Plan: • Revised Procedures for Review and Approval: i. The FEMA Public Assistance Grants Coordinator will be responsible for completing the Project Application Summary Reports. ii. Upon completion, the Grants Coordinator will upload all supporting documents into the FEMA Grants Portal. The system automatically timestamps each document and records the name of the individual who uploaded it, ensuring clear documentation of the review process. iii. After all required documents are uploaded, the OCPW Emergency Manager will be notified that the project application is ready for review. iv. The OCPW Emergency Manager will then: 1. Review the submitted documents in the FEMA Grants Portal. 2. Confirm that the reported costs align with the information provided by the reporting County agency. 3. Approve and submit the project application to Cal OES and FEMA for project approval. • Retention of Documentation: i. The FEMA Grants Portal serves as the official system of record, ensuring all uploaded documents are timestamped and traceable. ii. All project application approvals, cost documentation, and required forms will be retained electronically within the system for audit and compliance purposes. • Training and Implementation: i. Staff responsible for grant reporting will receive training on the revised process, including proper document upload procedures and compliance expectations. ii. The updated process will be implemented immediately. • Monitoring and Compliance: i. The OCPW Emergency Manager will conduct semiannual internal reviews of project applications to ensure compliance with the updated procedures. ii. Any issues identified during internal reviews will be addressed through additional staff training and process improvements. 3. Anticipated Implementation date: Immediate, March 18, 2025 • Staff Training: Within 30 days • Semiannual Compliance Review: Beginning next quarter i. First review will take place May 1, 2025. Followed by another review in October 2025.
Finding 547622 (2024-002)
Significant Deficiency 2024
Finding 2024-002 – Reporting Name of Contact Person: Karen Rimmer, County Clerk Corrective Action Plan: Reporting for federal grants falls under the department submitting the grant per the County Procurement Policy. Guidance will be developed to compliment policies in place to ensure reporting is co...
Finding 2024-002 – Reporting Name of Contact Person: Karen Rimmer, County Clerk Corrective Action Plan: Reporting for federal grants falls under the department submitting the grant per the County Procurement Policy. Guidance will be developed to compliment policies in place to ensure reporting is completed timely. This guidance will include best practices for document retention and resources for questions and/or difficulty with reporting portals. Additional training will be attended by appropriate staff, including the County Clerk, to ensure compliance requirements are understood and met. Some of this training has already taken place. Proposed Completion Date: Fiscal year ended June 30, 2025.
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information capt...
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information captured and reported. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management...
A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management implemented changes to the capturing and files maintained for documenting a participant’s eligibility for participation in program services. Management will continue to evaluate their controls with respect to current federal awards and requirements to ensure accurate information captured, reported and maintained. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings ...
Department of Health and Human Services TASC of Northwest Ohio respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT None FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2024-001 Improper controls over allocation of salaried employees time and effort. Recommendation: Implement strategy of using time and effort documentation in determining payroll costs charged to grants Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TASC of Northwest Ohio will implement a policy that includes a lookback and reconciliation to time and effort recorded by salaried employees to ensure that time is accurately charged to grants. Name(s) of the contact person(s) responsible for corrective action: Jason Pollick, Executive Director Planned completion date for corrective action plan: January 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Sonya Sparks at 419-242-9955.
Finding 547610 (2024-002)
Significant Deficiency 2024
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the req...
2. Identifying Number: 2024-002: Enrollment Reporting Finding: During the course of our special tests and provisions, we identified 3 students from a sample of 25 where the number of days between the enrollment change and reporting to National Student Loan Data System (NSLDS) was not within the required 60 days. We also identified 3 students from our sample of 25 whose withdrawal date was reported as the day after the withdrawal began and 1 student whose withdrawal date was reported as the end of the semester in which the student was attending. We also identified 2 students from our sample of 25 who were reported as withdrawn instead of graduated. Corrective Action Taken or Planned: Actions Taken The University has already taken corrective action on this finding. The issues raised were addressed in the following ways: number of days between the enrollment change and reporting was not within the required 60 days Graduate File Corrections: We discovered (Fall 2023) an error in the reporting of graduates, despite timely reporting via Degree Verify. Upon this discovery, we met with the National Student Clearinghouse (NSC) to determine the cause of the issue and how to correct it. We learned that students with enrollment in more than one program, or where the program reported did not match the program on record with NSC, were not being properly processed with a G status via the Degree Verify submissions. We were informed that this is common for institutions where students may be enrolled in more than one program at a time. We were advised by NSC to submit a “Graduates only” file, in addition to the Degree Verify file submission. Upon discovering this, we submitted Graduates only files for branches 02, 03, 04, 05, 80, 82, 84, and 97, for all terms for 2020, 2021, 2022, and 2023 beginning in December 2023 and ending in April 2024. We worked through these submissions with NSC, and incorrect withdrawn statuses were corrected to graduated statuses. Antioch’s enrollment reporting process has been updated to include a monthly submission of a graduates only file in addition to degree verify file monthly submission. The University has experienced changes in staffing for personnel involved in enrollment reporting. The person previously in charge of Enrollment Reporting retired on 02/29/24. He was responsible for the enrollment reporting for the majority of this audit period, as well as the prior year. Antioch University hired a new Director of Records Administration with a primary responsibility for NSLDS reporting on 03/28/24. The University has implemented a comprehensive training plan, including improved documentation of procedures, increased clarity regarding the process for the necessity of error resolution, and a review of system processing to help reduce errors in reporting and increase efficiency. The review of current practice and improved procedures was in conjunction with consultants from AACRAO, NSC, Ellucian (the student information system company). Actions Planned The University plans for corrective action on this finding. This includes policy updates for withdrawal processing and implementation of internal audits. Withdraw date was reported as the day after the withdraw began. It has been the practice to process withdrawal requests in this way: When a student withdrawal is submitted, the notification date is considered the last date of active enrollment. The withdraw (W) status begins effective on the following date. This has not been raised as a finding in prior audits. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c). For withdrawal processing effective immediately, this process will be updated to start the withdrawal on the date the student provides official notification, rather than starting on the day following. This means the last date attended and the start of the withdrawal will be the same date. Per the CFR 668.22(c). the student's withdrawal date is—(ii) The date, as determined by the institution, that the student otherwise provided official notification to the institution, in writing or orally, of his or her intent to withdraw; For withdrawal processing effective at the end of the term, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. Per the Withdrawal versus Graduation and Effective Dates section of the NSLDS Manual Nov 2022, p.23 - In the case of the student who completes a term and does not return for the next term, leaving the course of study uncompleted, the effective date for the ‘W’ status is the final day of the term in which the student was last enrolled. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Withdraw date was reported as the end of the semester in which the student was attending It has been the practice to process withdrawal requests in this way: When a student requests withdrawal but has completed courses, the grades are updated prior to processing the withdrawal request. The withdrawal is effective on the start date of the next term. This process will be updated (effective April 1, 2025) to follow 34 CFR 668.22(c) and the NSLDS Manual as outlined in the prior bullet point. For students withdrawing immediately from a term in which they’ve already completed one or more courses, the effective date for the ‘W’ status is the date AU is notified. However, they will only be dropped from courses still in progress. Completed courses cannot be withdrawn. The policy and process will be updated and training will occur to begin this processing change effective April 1, 2025. Reported as withdrawn instead of graduated The Grads Only submission did not return student records for 24SPTRI. We will need to review this with Ellucian to determine the issue. Once this is determined, we will re-run the submission for this term to update records. An internal audit process will be implemented to spot check 3-5 records on each submission for enrollment, grads only, or degree verify reporting. In addition, an audit report will be created to review 9 sample records on a quarterly basis from the current list of active students and the last two years of graduated and withdrawn students. The review will select 3 records from each status. An audit log will document these reviews. Person Responsible for Corrective Action: The Registrar and Executive Director of Financial Aid & Scholarships are responsible for executing the corrective action plan. The Executive Director of Financial Aid and Scholarships and the University Registrar will meet on a recurring basis to jointly review enrollment reporting procedures and National Student Loan Data System (NSLDS) reporting timelines. This collaboration ensures that all enrollment data submitted for Title IV purposes is accurate, timely, and aligned with institutional policies and federal regulations. Any discrepancies or issues identified are addressed collaboratively and corrective steps are documented. Anticipated Completion Date: Fiscal year 2025
Finding 547609 (2024-001)
Significant Deficiency 2024
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The U...
1. Identifying Number: 2024-001: Title IV Refund and Return of Funds Compliance Issue: A sample review found instances where Title IV refunds were miscalculated and not returned within the required timeframe. Cause: Administrative oversight led to inaccurate and untimely calculation. Effect: The University did not fully comply with FSA Handbook and federal regulations for returning Title IV aid in a timely manner. Corrective Actions Underway 1. Enhanced Quality Assurance Measures Implementation of a new review protocol for Title IV refund calculations, including a secondary verification process before fund returns. Establishment of a biweekly internal audit of refund calculations to identify and resolve errors before submission. 2.Ongoing Compliance Monitoring and Prevention Efforts Establishment of a quarterly compliance review conducted by the Financial Aid leadership team to proactively address potential issues. Development of a standardized documentation process for all Title IV transactions and NSLDS updates to ensure clear audit trails. Creation of staff retraining initiative to reinforce compliance expectations and best practices. Next Steps: Conduct a full compliance assessment at 30, 60, and 90 days to confirm improvement and adjust protocols as needed. Establish a reporting dashboard for real-time tracking of Title IV refunds and enrollment status updates. Formalize a policy review cycle to ensure that all processes remain aligned with the latest federal regulations. These actions are intended to strengthen the University’s compliance posture, mitigate risks, and enhance the accuracy and timeliness of financial aid administration. Please let me know if additional measures or oversight mechanisms should be considered. Person Responsible for Corrective Action:The Executive Director of Financial Aid & Scholarships is responsible for executing the corrective action plan. Anticipated Completion Date: Fiscal year 2025
Audit Finding Number 2024-001: The audit of the financial statements identified adjustments to the current year financial statements that were considered to be material. Management’s Response to the Finding and Recommendation: Management understands and agrees the corrections are required to the 2...
Audit Finding Number 2024-001: The audit of the financial statements identified adjustments to the current year financial statements that were considered to be material. Management’s Response to the Finding and Recommendation: Management understands and agrees the corrections are required to the 2024 financial statements and is in agreement with the finding and the related recommendations. Action(s) to be Taken or Planned to be Taken on the Finding: The 2024 financial statements have been corrected to properly present the financial statement amounts. Management will review its process for the preparation of financial statements and evaluation of transactions in accordance with generally accepted accounting principles for proper recording of balances and amounts going forward. Anticipated Completion Date: Completed November 2024
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