Corrective Action Plans

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Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the anal...
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the analysis for each indicator and provide verification of all findings. Person Responsible: Annette Carper, Executive Director Anticipated Completion Date: I have completed the SEMAP training. The FYE 2025 SEMAP is due to be submitted by July 31, 2025. I will prepare a binder that will show collected data from August 1, 2024-July 31, 2025.
We are reviewing all accounting procedures to determine changes to be implemented.
We are reviewing all accounting procedures to determine changes to be implemented.
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
2024-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2025
Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants 84.010 Child Nutrition Cluster 10.553, 10.555, 10.559 Impact Aid 84.041 Education Stabilization Fund 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: ...
Finding Number: 2024‐001 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants 84.010 Child Nutrition Cluster 10.553, 10.555, 10.559 Impact Aid 84.041 Education Stabilization Fund 84.425 Contact Person: Arlene Laughter, Business Coordinator Anticipated Completion Date: December 30, 2025 Planned Corrective Action: The District will implement better controls over financial reporting and records retention to ensure all documents are prepared and available for the timely completion of the financial reports.
District will work closely with external auditors with an initial calendar to meet the required deadline for next year’s (fiscal year 2025) audit.
District will work closely with external auditors with an initial calendar to meet the required deadline for next year’s (fiscal year 2025) audit.
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Fina...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2025 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Due to non-compliance with timely and accurate student enrollment change submissions to the National Student Loan Data System (NSLDS), Brigham Young University – Hawaii (BYUH) Management proposes the following corrective action plan to mitigate reporting errors. The Registrar’s Office, in coordination with BYUH’s Enterprise Information Systems team, will review and enhance the processes used to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse (NSC) and NSLDS. This includes: -Reviewing all relevant PeopleSoft updates and ensuring that corresponding changes are reflected in the data transmitted to NSLDS. -Testing and validating the reporting processes within PeopleSoft to confirm data accuracy and completeness. -Verifying that the correct data is being transmitted to NSLDS. -Testing the student data within NSLDS to ensure its integrity. -Documenting the entire process for future reference and ongoing quality assurance. In addition, the Registrar’s office has already added additional resources to run all reporting processes. The Registrar’s office has also reached out to Ensign College to learn about their reporting process. The University is considering contacting the PeopleSoft reporting specialist that Ensign used, although that decision will be made at a later date, and if necessary. These actions will enable the Registrar’s Office to more effectively review credit load determinations and accurately establish program begin dates for students. Daryl Whitford, Registrar, will remain responsible for enrollment reporting at BYUH. She will oversee the implementation of the revised process, provide training to all relevant staff members, and lead the development and implementation of a control mechanism to ensurefuture compliance with NSLDS reporting requirements within PeopleSoft. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that all items noted in the corrective action plan will be implemented by September 1, 2025. Signed and Acknowledged Daryl Whitford, BYUH Registrar
2024-004 – Material Weakness – Noncompliance in Reporting Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Management will put processes into place to ensure an auditor is engaged to complete a s...
2024-004 – Material Weakness – Noncompliance in Reporting Federal Agency: U.S. Department of Agriculture, Rural Development, CFDA #10.766 Community Facilities Loans and Grants Cluster Corrective Action Plan: Management will put processes into place to ensure an auditor is engaged to complete a single audit in accordance with the Uniform Guidance to complete timely submission to the Federal Audit Clearinghouse of the audit report and data collection form. Responsible Party: Mariah Voeltz, Acting Administrator Estimated completion date: June 30, 2025
Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-001 – Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, ...
Management Views and Corrective Action Plan Year Ending December 31, 2024 Finding 2024-001 – Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan Campus Status Matt Smith, College Registrar, will work with Tom Cote, NSC Enrollment Reporting Consultant, to adjust the enrollment report produced by PeopleSoft. With this change, PeopleSoft will report a student's campus-level enrollment as withdrawn when they withdraw in the middle of a semester instead of leaving them as less than half-time. Program Status Matt Smith, College Registrar, and Riley Niemand, Director of Financial Aid, will use the NSLDS Enrollment Error Report to reconcile what is being reported from NSC to NSLDS to ensure it is accurate. Timing Campus Status Matt Smith is currently working with Tom Cote to make these changes and work will be completed by the end of May 2025. Program Status Matt Smith and Riley Niemand will have this reconciliation implemented by the end of June 2025. Sincerely, S. Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to thi...
Finding #2: Untimely Return of Title IV Funds (R2T4) Criteria: Under 34 CFR 668.22(j), institutions must return unearned Title IV funds no later than 45 days from the date the institution determines that a student has withdrawn. Condition: Six R2T4s were submitted late. While four were linked to third-party service platform transitions, two delays were related to students experiencing hardship (homelessness and mental health emergencies) and internal documentation gaps. Effect: Noncompliance with R2T4 deadlines may result in program findings, increased liabilities, and recurring audit scrutiny if unresolved. Corrective Actions for R2T4: 6. R2T4 Tracker Implementation o Action: Launch a live R2T4 tracker in Campus Café, flagged by withdrawal status and showing days remaining until the 45-day deadline. o Due Date: May 15, 2025 o Lead: Registrar, Business Office, Financial Aid Lead 7. Case Ownership Assignment Protocol o Action: Assign R2T4 responsibility to ECM and Business Office, written timelines and escalation criteria. o Due Date: May 15, 2025 o Lead: Executive Director 8. R2T4 Checklist & Escalation Framework o Action: Finalize a standardized checklist for all R2T4 cases including withdrawal date, calculation verification, fund return confirmation, and dual review. o Due Date: May 15, 2025 o Lead: Operations Manager 9. Quarterly R2T4 Audit o Action: Conduct quarterly compliance audits on all R2T4 files and include findings in compliance reports. o Due Date: First audit by June 30, 2025 o Lead: Compliance Officer 10. Emergency Circumstance Protocol o Action: Document a formal protocol for handling R2T4 cases with student hardship that allows internal escalation, verification, and documentation of exception handling. o Due Date: July 1, 2025 o Lead: Executive Director Monitoring Plan: Compliance will provide a quarterly report on R2T4 timeliness to the Executive Director. Any case that nears 35 days will be auto escalated for executive intervention.
Finding #1: Delayed or Incomplete Enrollment Reporting Criteria: Per 34 CFR 685.309(b), institutions must report student enrollment status changes (withdrawals, graduations, leaves of absence) within 30 days of determination or every 60 days using a consistent reporting schedule. Condition: Enrollme...
Finding #1: Delayed or Incomplete Enrollment Reporting Criteria: Per 34 CFR 685.309(b), institutions must report student enrollment status changes (withdrawals, graduations, leaves of absence) within 30 days of determination or every 60 days using a consistent reporting schedule. Condition: Enrollment changes for several students were not reported to NSLDS within the required timelines. Delays resulted from third-party servicer (ECM) processing issues, gaps in cross-verification, and lack of internal triggers for mid-enrollment aid recipients. Effect: Untimely reporting may result in incorrect loan repayment statuses for borrowers and may trigger additional oversight by the Department of Education. Corrective Actions for Enrollment Reporting: 1. Shared Operational Calendar with Alerts o Action: Expand the institutional calendar to include enrollment reporting cycles with automated alerts 15 and 5 days before reporting deadlines. o Due Date: May 15, 2025 o Lead: Registrar 2. Internal Monthly Cross-Verification Audit o Action: Reconcile Campus Café enrollment records with ECM NSLDS batch confirmations monthly to catch and correct discrepancies. o Due Date: Begins May 2025, ongoing o Lead: Compliance Officer 3. Enhanced Title IV Status Tracking o Action: Update batch tracker template to log when students begin receiving Title IV aid after initial enrollment, with clear notation requirements. o Due Date: May 15, 2025, Ongoing o Lead: Registrar 4. Targeted Staff Training o Action: Deliver internal training on accurate Title IV status coding and enrollment reporting procedures to Registrar and Business Office teams. o Due Date: May 15, 2025 o Lead: Executive Director & Registrar 5. Bi-Monthly Enrollment Reporting Review o Action: Conduct a compliance review every 8 weeks to assess reporting timeliness and documentation quality. o Due Date: Begins May 2025 o Lead: Compliance Officer Monitoring Plan: Compliance team will issue bi-monthly reports to the Executive Director summarizing reporting performance and identifying risk patterns.
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding...
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the review of program reporting and campus reporting, the college will identify the cause for the data error. The college will explore the impact of branch campuses and the potential to shift to a single college reporting model. The following specific steps will be completed. 1. Identify and Analyze the Issues 2. Root Cause Analysis 3. Corrective Measures 4. Automation: Implement automated checks and balances to ensure data integrity before files are processed and sent. Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Cheryl Eldredge, College Associate Dean for Registrar and Master Schedule Planned completion date for corrective action plan: December 31, 2026
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College shoul...
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College should evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS aligns with the College’s last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the work of a college-wide task force the following actions will be taken in response to the finding. The task force will include representatives from Information Technology, Institutional Research, Financial Aid, Registrar, along with Ellucian consultants. To summarize the steps and details of implementation to the specific areas are as follows: 1. Review Reporting Controls and Procedures 2. Address Error Code 22 3. Review Procedures Surrounding Reporting Status Changes 4. Assure Accuracy in Reporting Enrollment Effective Date Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Planned completion date for corrective action plan: December 31, 2026
Views of Responsible Officials: All Astraea staff members are required to complete timesheets. Astraea’s internal processes were reviewed and overhauled in December 2021 (midway through FY2022) with department heads determining how their direct reports would spend time on various Astraea work stream...
Views of Responsible Officials: All Astraea staff members are required to complete timesheets. Astraea’s internal processes were reviewed and overhauled in December 2021 (midway through FY2022) with department heads determining how their direct reports would spend time on various Astraea work streams and projects. This information is detailed in a level of effort (LOE) spreadsheet tracked against timesheets and budgets regularly. However, the processes for instituting regular updates to the LOE spreadsheet and timesheet allocations remained time-consuming and highly manual in FY2023 – which we believe resulted in misallocations. Astraea is currently reviewing internal processes to ensure, 1) that review and revision of the LOE spreadsheet and timesheet allocations can happen in a timely manner with less administrative burden, and 2) allowance of a more detailed review of the payroll allocation approval and entry process. As of January 1, 2025, a new finance system was implemented allowing for greater sophistication, consistency and automation of these processes. We do not expect to see this finding upon completion of our FY25 audit.
Those charged with governance agreed with the finding and will work to maintain tenant files in accordance with legislation, regulations, and the terms and conditions of the major federal award program.
Those charged with governance agreed with the finding and will work to maintain tenant files in accordance with legislation, regulations, and the terms and conditions of the major federal award program.
Views of Responsible Officials: The Grants manager and Grants Compliance manager positions had turnover in 2024. The search for their replacements continues. With various temporary staff filling the roles in 2024, delays occurred in meeting reporting deadlines. Management has reviewed all agreements...
Views of Responsible Officials: The Grants manager and Grants Compliance manager positions had turnover in 2024. The search for their replacements continues. With various temporary staff filling the roles in 2024, delays occurred in meeting reporting deadlines. Management has reviewed all agreements to ensure its tracking tools reflect all relevant due dates for financial and narrative reports, as required by the agreements. These tracking tools will be monitored monthly to ensure timely submissions of reports by the established due dates.
Finding 560570 (2024-001)
Significant Deficiency 2024
Name of Contact Person: Elizabeth Shavelson, Assistant Chief Financial Officer Corrective Action: The City has established a timeline and identified milestones for its audit and financial reporting process for the Fiscal Year Ended June 30, 2025. The City will initiate the process much earlier to a...
Name of Contact Person: Elizabeth Shavelson, Assistant Chief Financial Officer Corrective Action: The City has established a timeline and identified milestones for its audit and financial reporting process for the Fiscal Year Ended June 30, 2025. The City will initiate the process much earlier to allow more time for completion and will continue to track and monitor is progress against its established milestones throughout the process. Along with filling vacant staff positions, the City has engaged a consultant to assist the Finance Department in developing and enhancing documentation specific to financial reporting procedures. The City has also been working with its financial software support team to streamline certain ERP system configurations in order to improve the City’s financial reporting process. Proposed Completion Date: 12/31/2025
Management Response: Management concurs with the finding and will reconcile the College’s disbursement records with the federal COD system and correct all errors on a monthly basis.
Management Response: Management concurs with the finding and will reconcile the College’s disbursement records with the federal COD system and correct all errors on a monthly basis.
View Audit 356480 Questioned Costs: $1
Management Response: The College acknowledges and concurs with the finding. The College is in the process of implementing changes to the student information systems and related process to accommodate both the internal enrollment polices and required reporting statuses, and enhances monitoring proces...
Management Response: The College acknowledges and concurs with the finding. The College is in the process of implementing changes to the student information systems and related process to accommodate both the internal enrollment polices and required reporting statuses, and enhances monitoring processes to ensure the integrity and punctuality of data reported to the NSLDS.
Housing Opportunities for Persons with AIDS – Assistance Listing No. 14.241 Recommendation: We recommend the Organization design controls to ensure the payroll data is reviewed prior to being paid out and the support is reviewed in detail when submitting to the grantor for reimbursement. Explanation...
Housing Opportunities for Persons with AIDS – Assistance Listing No. 14.241 Recommendation: We recommend the Organization design controls to ensure the payroll data is reviewed prior to being paid out and the support is reviewed in detail when submitting to the grantor for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Aids Taskforce of Greater Cleveland, Inc. will continue to review payroll as internal controls state and ensure accurate reporting. Control with payroll should be coordinated with payroll department ensuring duplicate payroll is not being processed and approved. Name(s) of the contact person(s) responsible for corrective action: Simpson Huggins Planned completion date for corrective action plan: December 31, 2025 If the Oversight Agency has questions regarding this plan, please call Simpson Huggins 216-621-0766
View Audit 356447 Questioned Costs: $1
The District will implement a process to track the submission time of the data collection form and audit package.
The District will implement a process to track the submission time of the data collection form and audit package.
2024-002 Finding: Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) At this time, the District will accept the degree of risk associated with this condition. For future audits, we will continue to review the financial statements and SEFA in detail and agree ...
2024-002 Finding: Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) At this time, the District will accept the degree of risk associated with this condition. For future audits, we will continue to review the financial statements and SEFA in detail and agree to internal records and expectations. The General Manager is responsible for the corrective action plan for this finding.
Finding 560528 (2024-002)
Significant Deficiency 2024
Condition: Obligations and expenditures were overstated by $93,955 on the March 31, 2024 Project and Expenditure report. Corrective Action Planned: Town Administrator will work with CSS Capital Strategic Solutions LLC to potentially amend the filing with the Treasury. Anticipated Completion Date...
Condition: Obligations and expenditures were overstated by $93,955 on the March 31, 2024 Project and Expenditure report. Corrective Action Planned: Town Administrator will work with CSS Capital Strategic Solutions LLC to potentially amend the filing with the Treasury. Anticipated Completion Date: End of 2025 Contact: Town Administrator Nelson Mui, nmui@townsendma.gov, 978-597-1700 x1703
Name of Auditee: California Community Foundation (CCF) Audit Period: Year Ended June 30, 2024 Finding Reference #: 2024-003 – Reporting Finding Description: The Single Audit report identified a reporting-related finding (2024-003) associated with the Coronavirus State and Local Fiscal Recovery Funds...
Name of Auditee: California Community Foundation (CCF) Audit Period: Year Ended June 30, 2024 Finding Reference #: 2024-003 – Reporting Finding Description: The Single Audit report identified a reporting-related finding (2024-003) associated with the Coronavirus State and Local Fiscal Recovery Funds under the U.S. Department of Treasury. The Foundation overstated expenditures by $203,329 and the corresponding indirect costs by $20,363 in the Schedule of Expenditures of Federal Awards (SEFA). Additionally, discrepancies were noted in the June 30, 2024 Quarterly Performance Report to the County, where advances to vendors were overstated by $120,000 and vendor-incurred expenditures were understated by $519,259. This condition reflects a gap in internal controls that could impact accurate financial reporting. Corrective Action Planned: CCF acknowledges the finding and is implementing corrective measures to strengthen the accuracy and integrity of its financial and programmatic reporting. CCF has enhanced its internal review process and implemented a reconciliation protocol to ensure consistency between internal records and external reports. Finance staff have received additional training, and final reports are now subject to dial validation by both the Compliance and Finance teams prior to submission. Anticipated Completion Date: Corrective action will be implemented by May 15, 2025. Responsible Official(s): Jose Najera, Sr. Compliance & Operations Officer (213) 452-6218 – jnajera@calfund.org Management Comments: CCF remains committed to maintaining robust internal controls and ensuring compliance with all applicable federal requirements. We appreciate the audit team’s observations and will continue enhancing our procedures to prevent future discrepancies and to uphold the highest standards of financial integrity and transparency.
Finding 560522 (2024-003)
Significant Deficiency 2024
Aclamo
PA
Reporting – reports submitted to the county for the ARPA contract were not retained, effective internal controls were not in place to ensure proper document retention. ACLAMO acknowledges and agrees with Finding 2024-003 regarding the lack of effective internal controls to ensure the retention of re...
Reporting – reports submitted to the county for the ARPA contract were not retained, effective internal controls were not in place to ensure proper document retention. ACLAMO acknowledges and agrees with Finding 2024-003 regarding the lack of effective internal controls to ensure the retention of reports submitted to the County under the ARPA contract. To address this issue, the Interim Executive Director, in coordination with the Financial Team, has taken the following corrective actions: Quarterly Report Oversight: The Interim Executive Director will assume responsibility for submitting all required quarterly reports related to ARPA funding. This ensures a single point of accountability for timely and accurate reporting. Document Retention and Audit Readiness: Immediately following each report submission, ACLAMO will request confirmation of receipt and a copy of the submitted report from the County. These documents will be promptly uploaded and stored in ACLAMO’s Financial Team SharePoint Site to ensure secure access and proper audit documentation. Internal Control Enhancements: ACLAMO will also implement a formal tracking system (such as a report log) to document submission dates, confirmation receipts, and responsible staff members. This log will be reviewed quarterly by the Financial Team to ensure completeness and compliance. Staff Training: Relevant team members will receive training on proper document retention procedures, the importance of audit trails, and use of the SharePoint system to reinforce accountability and sustainability of this corrective action. ACLAMO is committed to improving its reporting systems and internal controls to ensure compliance with all federal and contractual requirements and to promote transparency and accountability.
The Organization acknowledges the significance of maintaining adequate staffing in the accounting department to prevent overburdening individuals with excessive responsibilities during the year-end closing process. In light of this, we have taken the following corrective action: (1) we have hired ad...
The Organization acknowledges the significance of maintaining adequate staffing in the accounting department to prevent overburdening individuals with excessive responsibilities during the year-end closing process. In light of this, we have taken the following corrective action: (1) we have hired additional accounting staff during the fiscal year ending June 30, 2025 and (2) we have designated a high-level accounting manager to closely monitor and oversee the accounting function.
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