Corrective Action Plans

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Improper Time & Effort Reporting Condition: 2 CFR 200.430 of the Uniform Guidance mandates that personnel compensation charged to federal awards must be based on records that accurately reflect the work performed. When an employee works on multiple cost objectives (e.g., multiple awards or activitie...
Improper Time & Effort Reporting Condition: 2 CFR 200.430 of the Uniform Guidance mandates that personnel compensation charged to federal awards must be based on records that accurately reflect the work performed. When an employee works on multiple cost objectives (e.g., multiple awards or activities), this often necessitates the use of personnel activity reports or similar timekeeping documents to accurately allocate salaries and wages. During the audit, we found that proper personnel activity reports were not being maintained for multiple cost objective employees charged to Title IV and to the Special Education Cluster. While we were able to support that the amounts charged to the grants were reasonable, through review of the employee's Outlook calendars, daily schedules, etc., the documentation required by federal guidance was not available. We recommend that management provide training to all multiple cost objective employees on how to properly document their time and then to Implement oversite procedures requiring that those personnel activity reports be submitted to management for review on a monthly basis. Corrective Action: The District has begun training all staff and grant Directors on the proper documentation required to properly support the time and effort employees spend on various grants. In addition, the Grant Director will begin reviewing this documentation on a periodic basis, to ensure complete compliance. Contact Person Responsible for Corrective Action: Chanda Cleaves, Executive Director of Finance Completion Date: This issue will be corrected moving forward.
Management has made an ongoing evaluation of the respective costs and benefits of obtaining internal or external resources, specifically for the preparation of financial statements, and has determined that the additional benefits derived from implementing such a system would not outweigh the costs i...
Management has made an ongoing evaluation of the respective costs and benefits of obtaining internal or external resources, specifically for the preparation of financial statements, and has determined that the additional benefits derived from implementing such a system would not outweigh the costs incurred to do so. Management will continue to review the draft financial statements and notes prior to approving them and accepting responsibility for their content and presentation.
Condition: We examined a sample of Title IV aid recipients to verify that information reported on the Enrollment Reporting roster file sent to the National Student Loan Data System (NSLDS) matched the student's academic files and found instances where students received Title IV aid during a semester...
Condition: We examined a sample of Title IV aid recipients to verify that information reported on the Enrollment Reporting roster file sent to the National Student Loan Data System (NSLDS) matched the student's academic files and found instances where students received Title IV aid during a semester but the status of withdrawn or graduate were not reported timely on the NSLDS Enrollment Reporting roster files sent during that semester. Criteria: Per the NSLDS Enrollment Reporting Guide, a school should report all students that NSLDS includes in its request to the school on a roster file. This includes timely and accurate reporting of the status of the student of withdrawn or graduate. Cause: The status of the students were not timely reported to NSLDS. Effect: Students could potentially not be placed in grace or repayment status when they should be. Perspective: All withdrawn students tested were reported accurately, but there were a few fall students that were not submitted timely. Spring students tested were timely. The new Director came on in at the end of the June 30, 2024 year and worked to correct the reporting. The fall period was the first time through the submission, but by Spring, no issues remained. Recommendation: The College has moved up the initial reporting date after semester the semester ends to correct the timeliness issue. Views of Responsible Officials and Planned Corrective Actions: Dodge City Community College staff involved in enrollment reporting to the NSLDS agree with this finding and have already taken steps to ensure timely reporting in the future.
2025-004 Preparation of Schedule of Expenditures of Federal Awards and State Financial Assistance; District management believes that the cost of employing internal resources to draft the Schedule of Expenditures of Federal Awards and State Financial Assistanace Statement and related notes would outw...
2025-004 Preparation of Schedule of Expenditures of Federal Awards and State Financial Assistance; District management believes that the cost of employing internal resources to draft the Schedule of Expenditures of Federal Awards and State Financial Assistanace Statement and related notes would outweigh the benefits to be received. Furthermore, District management will continue to employ personnel who have the capability to review, approve and accept responsibility for the Schedule of Expenditures of Federal Awards and State Financial Assistance Statement.
2025-003 The District will update the policy and procedures for posting of cash transactions, including setting roles of those involved, implementing new reporting for ACH transactions, daily posting of transactions, reconciliation to the general ledger, and monthly Board reviews.
2025-003 The District will update the policy and procedures for posting of cash transactions, including setting roles of those involved, implementing new reporting for ACH transactions, daily posting of transactions, reconciliation to the general ledger, and monthly Board reviews.
2025-002 Preparation of Financial Statement; District management believes that the cost of employing internal resources to draft financial statements and related notes under the GASB 34 model, including the related GASB 24 conversion entries, would outweigh the benefits received. Furthermore, Distri...
2025-002 Preparation of Financial Statement; District management believes that the cost of employing internal resources to draft financial statements and related notes under the GASB 34 model, including the related GASB 24 conversion entries, would outweigh the benefits received. Furthermore, District management will continue to employ personnel who have the capability to review, approve and accept responsibility for the financial statements.
Contact Person Darin Scherr, Business and Operations Manager Corrective Action Plan The District agrees with the finding as presented. The Head Start department will ensure credit card expenditures, along with the other required financial information, are shared monthly with the governing body and t...
Contact Person Darin Scherr, Business and Operations Manager Corrective Action Plan The District agrees with the finding as presented. The Head Start department will ensure credit card expenditures, along with the other required financial information, are shared monthly with the governing body and the policy council. Corrective action has already taken place on a go forward basis starting when this was identified during a previous Head Start audit. Completion Date Immediately
In Finding 2025-005, a condition was noted in which the Federal Data Collection Form and audit report for the year ended May 31, 2024, were not submitted to the Federal Audit Clearinghouse until April 4, 2025, which was beyond the filing period of January 31, 2025. In response to Finding 2025-005, t...
In Finding 2025-005, a condition was noted in which the Federal Data Collection Form and audit report for the year ended May 31, 2024, were not submitted to the Federal Audit Clearinghouse until April 4, 2025, which was beyond the filing period of January 31, 2025. In response to Finding 2025-005, the Organization will ensure that the 2025 audit and Federal Data Collection Form is completed in a timely manner. The delay in filing for 2024 was a result of staff turnover.
Date: October 16, 2025 To: Angela Baker, Finance Director From: Melissa Johnson, Early Education Director CC: Candy Scott, Executive Director Subject: NC Pre-K Audit • Purpose: To provide information on the requested review documentation for 40 child files for an NC Pre-K audit. • Details: While gat...
Date: October 16, 2025 To: Angela Baker, Finance Director From: Melissa Johnson, Early Education Director CC: Candy Scott, Executive Director Subject: NC Pre-K Audit • Purpose: To provide information on the requested review documentation for 40 child files for an NC Pre-K audit. • Details: While gathering requested information for an NC Pre-K audit, it was discovered that 11 of the 40 requested children’s files did not have review information in our online application portal, Survey Apply. The applications were processed following all guidelines and procedures, and supporting documentation is available. These documents include income spreadsheets, scorecards, and the date entered in the APP system. The review information, however, is not available in the online application database, and the reason for this has not been determined. Jennifer Williams, Office Manager, and I have both tried to recover this information without success. The requested files missing this information are Kever Pinto, Jackson Millsap, Brixton Beale, Zoey Matthews, Amir Salimov, Nolan McCowan, Rex Klein, Caleb Bernabe, Joseph Holland, Ocean Davis, and Bryson Bunch. • Outcome/Action Taken: Discovery of this possible glitch in the online application system has led us to put additional processes in place to ensure that this information is available upon request in the future. In addition to maintaining a saved copy of the income spreadsheet and scorecard on our internal server, we will now begin saving a copy of the review for each application that is processed. We are in the process of updating our NC Pre-K guidelines. This change will be reflected in these guidelines.
Conditon: Two (2) monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Responsible Person:...
Conditon: Two (2) monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Responsible Person: Dr. Anita Rice, Superintendent Anticipated Completion Date: June 30, 2026
Finding 2025-001 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District will evaluate current procedures for accurately monitoring, recording, and reporting the num...
Finding 2025-001 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District will evaluate current procedures for accurately monitoring, recording, and reporting the number and type of meals served. 3. Official Responsible Mr. Kurt Stumpf, Superintendent, is the official responsible for ensuring corrective action. 4. Planned Completion Date June 30, 2026. 5. Plan to Monitor Completion The Board of Education will be monitoring this Corrective Action Plan.
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being re...
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being reimbursed an incorrect amount by the Michigan Department of Education. Planned Corrective Action: The Academy will implement proper procedures and controls to ensure meal counts are reviewed and agree to underlying records of meals served prior to submitting meal claims. Contact person responsible for corrective action: Molly Brown Anticipated Completion Date: 12/01/2025
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being re...
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being reimbursed an incorrect amount by the Michigan Department of Education. Planned Corrective Action: The Academy will implement proper procedures and controls to ensure meal counts are reviewed and agree to underlying records of meals served prior to submitting meal claims. Contact person responsible for corrective action: Molly Brown Anticipated Completion Date: 12/01/2025
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being re...
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being reimbursed an incorrect amount by the Michigan Department of Education. Planned Corrective Action: The Academy will implement proper procedures and controls to ensure meal counts are reviewed and agree to underlying records of meals served prior to submitting meal claims. Contact person responsible for corrective action: Molly Brown Anticipated Completion Date: 12/01/2025
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being re...
Condition: The Academy does not currently have a control in place where a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in incorrect reporting of the number of free and reduced priced meals, which could result in the Academy being reimbursed an incorrect amount by the Michigan Department of Education. Planned Corrective Action: The Academy will implement proper procedures and controls to ensure meal counts are reviewed and agree to underlying records of meals served prior to submitting meal claims. Contact person responsible for corrective action: Molly Brown Anticipated Completion Date: 12/01/2025
Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the in...
Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the institution, must be accurately reported within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. The changes include reductions or increases in attendance levels, withdrawals, graduations, and approved leaves of absence. It is the institution’s responsibility, as a participant in the Title IV aid programs, to monitor and report these changes to the National Student Loan Data System (“NSLDS”). (NSLDS Enrollment Reporting Guide November 2022 and 34 CFR 682.610) Condition Found Of the 16 students selected for enrollment reporting testing, seven students within the sample were reported to NSLDS outside the maximum 60-day window. This was not a statistically valid sample. Upon further inquiry, there were an additional 206 students included in the same batch reported to NSLDS that were not reported timely. Views of Responsible Officials and Planned Corrective Actions NELB is revising the use of the customized report to more accurately reflect student records and will leverage the student information system, Jenzabar, to produce enrollment reports. The Office of the Registrar, the Office of the Controller, and Office of Financial Aid will review the file for NELB graduates in the month of May and ensure 100% compliance with graduating reporting after submission. As part of the NELB year-end closing procedures, there will be an additional review in the month of June every year to ensure that the file of NELB graduates provided to the National Student Loan Data System is consistent and accurate. This year-end closing procedure will be initiated by the NELB Chief Financial Officer and will coordinate with the Office of Financial Aid, Office of the Registrar and the Controller’s Office. Names of Contact Persons Responsible for Corrective Action: Office of Financial Aid (Jenny Aquiar), Office of the Registrar (Max Brodsky) and the Controller’s Office (Sean Bendall). The NELB Chief Financial Officer (James White) will work collaboratively to ensure that the corrective action plan is completed by each of these three NELB departments by June 30, 2026. Anticipated Completion Date: June 30, 2026
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 157096-0 Award Year: October 1, 2022 – September 30, ...
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 157096-0 Award Year: October 1, 2022 – September 30, 2025 Compliance Requirement: Reporting Criteria: Per the grant agreements, Maricopa County Community College District Foundation (the “Foundation”) must submit several programmatic reports throughout the grant period with various due dates. Condition: A required programmatic report was submitted 6 days after the due date. Name of Contact Person: Judy Sanchez, Interim CEO Phone Number: 602-402-5062 Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action Plan: The Foundation will design and implement controls regarding the tracking of reporting due dates and retention of concurrent documentation when obtaining extensions or approval for late submissions.
The District agrees with this finding and will implement the following:  Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling.  Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of the populati...
The District agrees with this finding and will implement the following:  Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling.  Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of the population used to calculate and select samples.  Internal Review Process o Establish manual review process to confirm all required documentation and applications are retained and accurately represent the population.
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the enrollment effective date reported to NSLDS on the cam...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the enrollment effective date reported to NSLDS on the campus and program level is aligning with the University. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The Records Office at Union Adventist University submits an enrollment report to the National Student Clearinghouse every 30 days to ensure that the National Student Loan Data System (NSLDS) receives the most accurate and up-to-date information. If any errors are identified, the Clearinghouse returns them to the university for correction. The Records Office reviews all error reports and resolves any issues. To ensure that accurate enrollment data is reported to NSLDS within the required effective dates, Union Adventist University will review and resolve the errors within 3-5 business days. Name(s) of the contact person(s) responsible for corrective action: Nicole Houdek, Director of Records/Registrar Planned completion date for corrective action plan: May 2026
2025-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2025 Condition Found During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV ...
2025-001: Late Return of Title IV Financial Aid - Student Financial Aid Cluster - Assistance Listing #s 84.007, 84.033, 84.063, 84.268 - Grant Period - Year Ended June 30, 2025 Condition Found During our Return of Title IV Fund testing, we noted that the College did not calculate or return Title IV Student Financial Aid for one out of twenty-five students tested until after 45 days when the student ceased attendance. We consider the untimely calculation and Return of Title IV Student Financial Aid to be an instance of noncompliance relating to the Special Tests and Provisions Compliance Requirement. This is a repeat finding of prior year finding 2024-001. Corrective Action Plan We have done two things to help us process R2T4s within the required timeframe. First, we added a column to our initial withdrawal report that calculates when the 30-day limit will be for each student. This helps keep us on track for the 30-day deadline for when we must perfom the R2T4 calculation. This report was implemented in June 2025. Secondly, we created a new report called the ROF Transmittal Report. This weekly report shows us all students that have had an R2T4 done in Colleague for the current semester and it compares their awarded amount to their transmitted amount. This helps us identify students whose aid has not been disbursed within a week of the R2T4 calculation being performed. This report also promotes transparency and communication between the Financial Aid office and the Accounting Office in our respective parts of the R2T4 process. This report was implemented in February 2025. Responsible Person for Corrective Action Plan Kendra Souligne Implementation Date of Corrective Action Plan June 2025
Finding 2025-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Jarrett J Roethke Corrective Action Plan: Action 1: Establish Internal Reporting Calendar • Create a detailed internal reporting schedule that sets deadlines 15 days prior to the official due date. ...
Finding 2025-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Jarrett J Roethke Corrective Action Plan: Action 1: Establish Internal Reporting Calendar • Create a detailed internal reporting schedule that sets deadlines 15 days prior to the official due date. • Calendar will include responsible staff, required documentation, and checkpoints. Responsible Party: CFO Proposed Completion Date: Within 30 days Action 2: Implement a Reminder & Tracking System • Add all reporting deadlines to the shared organizational calendar with automatic reminders at 30, 15, and 5 days before the deadline. • Use a simple project-tracking tool (e.g., Smartsheet, Teams Planner, or internal system) to monitor report progress. Responsible Party: Grants Coordinator Proposed Completion Date: Within 45 days Action 3: Designate Backup Staff & Cross-Training Identify and train a secondary staff member to prepare and submit quarterly financial reports in the absence of the primary responsible employee. Create a documented checklist for the reporting process to support consistent review. Responsible Party: CFO, Grant Coordinator Proposed Completion Date: Within 60 days
The Office of the Registrar will continue to submit enrollment data to the National Student Clearinghouse via the current schedule. The Office of the Registrar will investigate and resolve any errors returned by the National Student Clearinghouse. After the enrollment data is transferred from the NS...
The Office of the Registrar will continue to submit enrollment data to the National Student Clearinghouse via the current schedule. The Office of the Registrar will investigate and resolve any errors returned by the National Student Clearinghouse. After the enrollment data is transferred from the NSC to NSLDS the Registrar's office will review the data in NSLDS for any discrepancies including cross-checking graduation files and complete withdrawals. Any inconsistencies will be discussed and timely resolved by the applicable units and officially updated in NSLDS and NSC respectively. The University will keep track of any changes manually made within the NSLDS or NSC database by university representatives, so that the student information system, NSC, and NSLDS records are in-sync.
Corrective Action Plan (Management Response): The District acknowledges the finding and has initiated corrective measures:1. Policy Development: Draft comprehensive written policies and procedures addressing procurement, allowable costs, eligibility, reporting, and record retention for all major fed...
Corrective Action Plan (Management Response): The District acknowledges the finding and has initiated corrective measures:1. Policy Development: Draft comprehensive written policies and procedures addressing procurement, allowable costs, eligibility, reporting, and record retention for all major federal programs. 2. Approval and Adoption: Policies will be reviewed and formally adopted by the Board of Trustees prior to acceptance of further federal grants. 3. Training and Implementation: Staff responsible for federal program administration will be trained on the new procedures. Training materials will include checklists and step by step guides to ensure consistent application. 4. Monitoring: The District will conduct quarterly reviews of federal programs (if applicable) to ensure compliance. Exceptions will be documented and corrective action taken immediately.
This finding will not completely resolve itself given the cost/benefit basis the Organization continues to make.
This finding will not completely resolve itself given the cost/benefit basis the Organization continues to make.
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