Corrective Action Plans

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JCCA CORRECTIVE ACTION PLAN March 23, 2026 Health Resources and Services Administration Jewish Child Care Association of New York (d/b/a JCCA) and Affiliated Organization respectfully submits the following corrective action plan for the year ended June 30, 2025. _____________________________________...
JCCA CORRECTIVE ACTION PLAN March 23, 2026 Health Resources and Services Administration Jewish Child Care Association of New York (d/b/a JCCA) and Affiliated Organization respectfully submits the following corrective action plan for the year ended June 30, 2025. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FINANCIAL STATEMENT FINDINGS Finding 2025-001 – Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Agency implement policies, procedures and controls to ensure that all accounting records are analyzed and reconciled on a monthly basis. Action Taken BTQ Financial is spearheading a comprehensive stabilization project to refine the chart of accounts and reconstruct historical tracking for the permanent endowment fund. BTQ already has in place a rigorous monthly closing schedule. This includes establishing automated reconciliation protocols for program service revenue, endowment tracking, and inter-company accounts to ensure GAAP compliance and timely board reporting. These policies, procedures, and controls to ensure that all accounting records are analyzed and reconciled on a monthly basis have already been incorporated into FY2026 monthly close process. Finding 2025-002 – Information Technology – General Control Activities SIGNIFICANT DEFICIENCY Recommendation We recommend the Agency follow their policy for password age. We also recommend the Agency perform a risk assessment over the information technology environment. We recommend a written risk assessment and penetration test to be performed annually and vulnerability scans to be performed quarterly. Action Taken The Agency has configured NetSuite and Active Directory to programmatically enforce password aging and complexity requirements that strictly mirror our established IT Security Policy. Furthermore, we have moved beyond interview-based assessments to an annual cadence of formal, written risk assessments and penetration testing, supported by continuous monthly vulnerability monitoring through our Security Operation Center (SOC). An interview-based risk assessment was performed in Q3 2025, and monthly vulnerability scans are managed by Arctic Wolf, our Security Operation Center (SOC) service provider. To further strengthen our posture, we will initiate an annual cadence of formal external and internal penetration tests starting in Q2-Q3 2026. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Unaccompanied Alien Children Program (Assistance Listing Number 93.676), FAIN # 90ZU0603, 90ZU0567, and 90ZU0536, for FY 2025 - Significant Deficiency Finding 2025-003 – Reporting Recommendation We recommend that management of the Agency implement procedures to track all federal reporting deadlines and ensure that reports are reviewed and submitted timely. This could include maintaining a centralized grant reporting calendar and implementing supervisory review prior to submission. Action Taken With the outsourcing to BTQ now fully operational, a centralized Federal Grant Reporting Calendar has been established. This calendar includes automated alerts for all 30/60/90-day deadlines. BTQ has also implemented a dual-level supervisory review process to ensure that all future reports are validated against the general ledger and submitted well in advance of federal deadlines. This protocol has been strictly applied to all federal reporting for the FY2026 cycle. U.S. Department of Health and Human Services, Unaccompanied Alien Children Program (Assistance Listing Number 93.676), FAIN # 90ZU0603, 90ZU0567, and 90ZU0536, for FY 2025 - Significant Deficiency Finding 2025-004 – Cash Management Recommendation We recommend that management of the Agency implement formal controls over the drawdown process that includes establishing procedures requiring documented supervisory review and approval of all drawdown requests and ensuring drawdowns are based on immediate cash needs so that federal funds are expended within a reasonable amount of time. Action Taken The Agency, in collaboration with BTQ Financial, has implemented a formalized "Drawdown Authorization Protocol." This new workflow improves upon the existing, and adds a standardized approach to every drawdown request, documented supporting schedules (showing immediate cash needs), and formal approval from BTQ’s PM, SVPF, VPF, or AVPF. This ensures a clear audit trail and prevents the accumulation of excess federal cash on hand. If the Health Resources and Services Administration has questions regarding this plan, please call Kenneth Shieh, Chief Administration Officer at (718) 747-4367. Sincerely yours, Kenneth Shieh, Chief Administrative Officer
Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury. Corrective Action Planned: Report differences to the U.S. Treasury will be corrected in the next report. Anticipated Completion Date: 4/30/2026 Contact: ...
Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury. Corrective Action Planned: Report differences to the U.S. Treasury will be corrected in the next report. Anticipated Completion Date: 4/30/2026 Contact: Matt Parent, Town Accountant
Management’s Response: Management concurs with the auditors’ finding and recommendation and will conduct a reconciliation between FEMA project worksheets and disaster event expenditures posted to Workday to ensure accurate reporting on the SEFA.
Management’s Response: Management concurs with the auditors’ finding and recommendation and will conduct a reconciliation between FEMA project worksheets and disaster event expenditures posted to Workday to ensure accurate reporting on the SEFA.
Management’s response: Management concurs with the auditors’ finding and recommendation. Metro Government will implement controls to ensure grant drawdown processes are followed, ensuring approvals are obtained before drawdowns are submitted and sufficient documentation is maintained by providing ad...
Management’s response: Management concurs with the auditors’ finding and recommendation. Metro Government will implement controls to ensure grant drawdown processes are followed, ensuring approvals are obtained before drawdowns are submitted and sufficient documentation is maintained by providing additional training to staff.
Management Response: Management concurs with the auditors’ finding and recommendation and will continue to provide training to staff to ensure expenditures are initially coded correctly to reduce the need for adjusting journals. Detailed and prompt review of grant expenditures will be done at least ...
Management Response: Management concurs with the auditors’ finding and recommendation and will continue to provide training to staff to ensure expenditures are initially coded correctly to reduce the need for adjusting journals. Detailed and prompt review of grant expenditures will be done at least quarterly and prior to drawdowns and financial reporting being submitted to funding sources.
Recommendation: We recommend the College evaluate its policies and procedures around reporting student status changes to NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: Ther...
Recommendation: We recommend the College evaluate its policies and procedures around reporting student status changes to NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Internal Control Enhancement: The Registrar will update the department’s internal control procedures to include a scheduled monitoring process to ensure that all enrollment status changes are reviewed and reported to NSLDS within 60 days. The procedure will also include a verification step to document when a student qualifies under the limited exception policy, ensuring appropriate justification is maintained for any enrollment updates reported outside the 60-day timeframe. Periodic reconciliation between the Student Information System and NSLDS reporting records will be conducted to confirm that all enrollment changes are transmitted within the required reporting period. Name(s) of the contact person(s) responsible for corrective action: Carrie Santaw, Bursar Planned completion date for corrective action plan: April 1, 2026
The Nutrition Cluster daily building counts that are submitted for the CEP program will be entered into Infinite campus daily and then the monthly number of counts in each building will be pulled from Infinite Campus and audited each month to make sure the paper backups match the totals in the syste...
The Nutrition Cluster daily building counts that are submitted for the CEP program will be entered into Infinite campus daily and then the monthly number of counts in each building will be pulled from Infinite Campus and audited each month to make sure the paper backups match the totals in the system and then the finalized numbers will be used to submit the month end claim to the state for reimbursement
Finding Number: 2025-033 ALN Number(s) and Program Title(s): 97.036 – Disaster Grants (Public Assistance) Views of Responsible Officials and Planned Corrective Action: Arkansas Division of Emergency Management (ADEM) Public Assistance (PA) staff will receive training on FFATA reporting requirements ...
Finding Number: 2025-033 ALN Number(s) and Program Title(s): 97.036 – Disaster Grants (Public Assistance) Views of Responsible Officials and Planned Corrective Action: Arkansas Division of Emergency Management (ADEM) Public Assistance (PA) staff will receive training on FFATA reporting requirements and will follow established Department of Public Safety guidelines to ensure first-tier subawards are reported as required. ADEM PA staff will also establish internal Standard Operating Procedures to ensure that consistent FFATA reporting is accomplished as required. Anticipated Completion Date: 4/30/26 Contact Person: Name: Jodi Lee Title: Deputy Director, Recovery and Mitigation Agency: Arkansas Division of Emergency Management Address: Building 9501 Camp Joseph T Robinson City, State, Zip: North Little Rock, AR 72199 Phone Number: (501) 683-6700 Email Address: Jodi.Lee@adem.arkansas.gov
Finding Number: 2025-030 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCO will continue periodic matching and review of state employees with public assistance pr...
Finding Number: 2025-030 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCO will continue periodic matching and review of state employees with public assistance programs administered by the agency. Appropriate disciplinary action will continue to be taken by the agency on its own employees based on the outcome of case reviews. The agency will explore the addition of systematic data matching to ensure that salaries of state employees are properly reflected in the eligibility determination and benefit calculation for public assistance benefits. For additional controls, the agency has incorporated a notice into the hiring process regarding reporting all changes in household circumstance and annual communications to all staff regarding their reporting obligations. Anticipated Completion Date: 6/30/26 Contact Person: Name: Mary Franklin Title: Director, Division of County Operations Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8377 Email Address: Mary.franklin@dhs.arkansas.gov
Finding Number: 2025-022 ALN Number(s) and Program Title(s): 93.658 – Title IV-E Foster Care Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCFS will conduct a review to determine if additional controls are needed to ensure that foster homes complete all...
Finding Number: 2025-022 ALN Number(s) and Program Title(s): 93.658 – Title IV-E Foster Care Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCFS will conduct a review to determine if additional controls are needed to ensure that foster homes complete all required checks. All improper Title IV-E payments will be returned on the next CB-496 quarterly report. Anticipated Completion Date: 4/30/2026 Contact Person: Name: Tiffany Wright Title: Director, Division of Children and Family Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-396-6477 Email Address: Tiffany.Wright@dhs.arkansas.gov
Finding Number: 2025-020 ALN Number(s) and Program Title(s): 93.658 – Title IV-E Foster Care Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The reconciliation process will be revised to specify steps to identify clients that are eligible to receive Title...
Finding Number: 2025-020 ALN Number(s) and Program Title(s): 93.658 – Title IV-E Foster Care Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The reconciliation process will be revised to specify steps to identify clients that are eligible to receive Title IV-E funding and the process to update their IV-E status. The agency could not make the necessary corrections in AASIS when notified of the deficiency due to the expenses being posted in the prior fiscal year. All necessary adjustments will be made on the quarterly report for the period ending on 3/31/26. Anticipated Completion Date: 4/30/26 Contact Person: Name: Tiffany Wright Title: Director, Division of Children and Family Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-396-6477 Email Address: Tiffany.Wright@dhs.arkansas.gov
Finding Number: 2025-019 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster) Views of Responsible Officials and Planned Corrective Action: DESE concurs with this fin...
Finding Number: 2025-019 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster) Views of Responsible Officials and Planned Corrective Action: DESE concurs with this finding. Staff turnover resulted in missing the reporting submission deadlines for the ACF-696 reports. New procedures have been put into place for cross-training and quarterly reconciliations to prevent future expenditure reporting on the ACF-696 report from being missed. Anticipated Completion Date: Completed. Contact Person: Name: Greg Rogers Title: Chief Fiscal Officer Agency: DESE Address: 4 Capitol Mall, Room 204-A City, State, Zip: Little Rock, AR 72201 Phone Number: 501-682-4475 Email Address: Greg.Rogers@ade.arkansas.gov
Finding Number: 2025-018 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund Views of Responsible Officials and Planned Corrective Action: DESE concurs with this finding. Staff tur...
Finding Number: 2025-018 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund Views of Responsible Officials and Planned Corrective Action: DESE concurs with this finding. Staff turnover resulted in missed reporting on the ACF-696 reports. New procedures have been put into place for cross-training and quarterly reconciliations to prevent future expenditure reporting on the ACF-696 report from being missed. Anticipated Completion Date: Completed. Contact Person: Name: Greg Rogers Title: Chief Fiscal Officer Agency: DESE Address: 4 Capitol Mall, Room 204-A City, State, Zip: Little Rock, AR 72201 Phone Number: 501-682-4475 Email Address: Greg.Rogers@ade.arkansas.gov
Finding Number: 2025-015 ALN Number(s) and Program Title(s): 21.029 – Coronavirus Capital Project Funds Views of Responsible Officials and Planned Corrective Action: ASBO acknowledges the auditor’s observation regarding cumulative obligation amounts reported for two projects in the Q2 2025 Project a...
Finding Number: 2025-015 ALN Number(s) and Program Title(s): 21.029 – Coronavirus Capital Project Funds Views of Responsible Officials and Planned Corrective Action: ASBO acknowledges the auditor’s observation regarding cumulative obligation amounts reported for two projects in the Q2 2025 Project and Expenditure Report submitted to the U.S. Department of the Treasury. The variances identified were the result of an administrative reporting error within a quarterly submission spreadsheet and did not reflect improper expenditures, questioned costs, or misuse of funds. The Agency identified the discrepancy during its internal review process and submitted corrected information to Treasury. By the time of audit review, the corrected reporting had already been provided. This issue was isolated to a specific reporting period and did not impact the underlying financial integrity of the projects. Anticipated Completion Date: June 30, 2026 Contact Person: Name: Glen Howie Title: State Broadband Director Agency: Arkansas State Broadband Office Address: 1 Commerce Way City, State, Zip: Little Rock, AR 72202 Phone Number: 501-683-6000 Email Address: broadband@arkansas.gov
Finding Number: 2025-006 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on com...
Finding Number: 2025-006 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on completion of the FNS-46 S-EBT and FNS-388 S-EBT reports. All noted reports have been revised, if necessary, reviewed, and certified. Staff have been trained on the updated procedures. Anticipated Completion Date: Complete Contact Person: Name: Renee Ikard Title: Chief Financial Officer Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8985 Email Address: Renee.Ikard@dhs.arkansas.gov
Finding Number: 2025-005 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on com...
Finding Number: 2025-005 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on completion of the FNS-425 S-EBT annual financial report. Staff have been trained on the updated procedures. Anticipated Completion Date: Complete Contact Person: Name: Renee Ikard Title: Chief Financial Officer Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8985 Email Address: Renee.Ikard@dhs.arkansas.gov
Noncompliance with Reporting Requirements
Noncompliance with Reporting Requirements
Criteria: The Organization’s agreements carry with them certain periodic reporting requirements that are due either fifteen days following the close of each month, or thirty days following the close of each quarter. Condition: We noted two instances in which certain required reports were submitted l...
Criteria: The Organization’s agreements carry with them certain periodic reporting requirements that are due either fifteen days following the close of each month, or thirty days following the close of each quarter. Condition: We noted two instances in which certain required reports were submitted late. Known Questioned Costs: None Likely Questioned Costs: None Context: As part of our testing of the quarterly reporting requirements for ALN 93.958, we noted two instances in which a required quarterly report was submitted after the required deadline. Cause: Management oversight. Effect: Untimely filing of reports could result in delays in future funding or funds received being returned to the grantor. Repeat Finding: No Recommendation: We encourage the Organization to continue its efforts to ensure that all contract reports are submitted timely in the future. Views of responsible officials and planned corrective action: Management is creating checklists to ensure all performance and financial reports are properly completed, reviewed, and timely filed.
Finding 2025-004 - Enrollment Reporting: Untimely Status Update Condition: One student who graduated in December 2024 was not reported within the required 60-day timeframe. Corrective Action Plan: The College will strengthen enrollment reporting controls within Colleague by: • Performing a monthly r...
Finding 2025-004 - Enrollment Reporting: Untimely Status Update Condition: One student who graduated in December 2024 was not reported within the required 60-day timeframe. Corrective Action Plan: The College will strengthen enrollment reporting controls within Colleague by: • Performing a monthly reconciliation between Registrar records and enrollment reporting files submitted to NSLDS. • Utilizing Colleague reporting tools to identify recent graduates and status changes requiring updates. • Establishing a compliance calendar with system reminders for required reporting deadlines. • Training staff on reporting requirements aligned with the National Student Loan Data System. Responsible Party: Mandy Schnorr, Director of Financial Aid, Cara Moyer, Registrar Anticipated Completion Date: June 30, 2026
Identifying Number: 2025-001 Finding: For sixteen out of forty students tested who had enrollment changes at the University, the student’s status effective dates at the campus level and program level were not reported to the NSLDS timely. Corrective Actions Taken or Planned: We agree with the findin...
Identifying Number: 2025-001 Finding: For sixteen out of forty students tested who had enrollment changes at the University, the student’s status effective dates at the campus level and program level were not reported to the NSLDS timely. Corrective Actions Taken or Planned: We agree with the finding. The delays in reporting were identified beginning in December 2024 with the hire of a new registrar and since that time we have caught up with reporting requirements are now timely. We have also increased our cross-training efforts in the department, training multiple individuals on NSC reporting procedures, in order to ensure that if turnover were to occur again in the future there are other individuals who can perform the required functions. Person(s) Responsible for Corrective Actions: Katie Soter, Registrar Anticipated Completion Date: Completed
Management has and will continue to work diligently with our auditor to make every reasonable effort to resolve this issue. Due to the cost-benefits of eliminating this condition, segregation of duties may continue to be a reportable condition. Currently management performs reviews of all aspects of...
Management has and will continue to work diligently with our auditor to make every reasonable effort to resolve this issue. Due to the cost-benefits of eliminating this condition, segregation of duties may continue to be a reportable condition. Currently management performs reviews of all aspects of the finance department including every payroll, monthly review of all expenditures; and monthly review of all accounts received.
Condition: The Organization failed to submit the quarterly activity report as of September 30, 2024 by October 30, 2024. The report was filed November 7, 2024. Planned Corrective Action: In addition to Calendar Task Reminders (created after receiving Grant Award) assigned to various teams and manage...
Condition: The Organization failed to submit the quarterly activity report as of September 30, 2024 by October 30, 2024. The report was filed November 7, 2024. Planned Corrective Action: In addition to Calendar Task Reminders (created after receiving Grant Award) assigned to various teams and managers, ECDI will add steps in the Grant Reporting Submission process to ensure reporting deliverables are met on time. Through its CRM system, ECDI will require Report documents to be both uploaded and reviewed prior to report deadlines. ECDI will also require uploading the confirmation that the document was provided to funder/partner. After these are reviewed by Development and Fiscal leaders, then the Task will be considered complete. Contact Person Responsible for Corrective Action: David Chew and Louisa Dallett Completion Date: In process
Condition: During eligibility testing of loan disbursements under the RMAP program, one of eight disbursements tested was made to a borrower located outside of the eligible area. The loan was disbursed in fiscal year 2025 for $10,000. Planned Corrective Action: The ECDI processing and loan allocatio...
Condition: During eligibility testing of loan disbursements under the RMAP program, one of eight disbursements tested was made to a borrower located outside of the eligible area. The loan was disbursed in fiscal year 2025 for $10,000. Planned Corrective Action: The ECDI processing and loan allocation teams will not exclusively leverage it’s CRM system for determining USDA eligibility based on borrower/business address. The team will use the USDA website in determining eligibility prior to allocating USDA funds to a project. Related to the specific ineligible $10,000 USDA loan, the team has communicated to its USDA partner to make them aware of this specific issue and ECDI is in the process of removing USDA funds and replacing with another source. Contact Person Responsible for Corrective Action: Brian Barrett and Sean Henderson Completion Date: In process
Condition: During our testing of allocated salaries and wages, we identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. One employee in each program, 59.046 and 93.570, had an inappropr...
Condition: During our testing of allocated salaries and wages, we identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. One employee in each program, 59.046 and 93.570, had an inappropriate wage rate applied to allocated time to the program. Additionally, for the 59.046 program only, one employee had compensation levels allocated to the program in excess of the Executive Level II Salary maximum amount in effect for the respective period. Planned Corrective Action: ECDI will put additional steps in place related to the Payroll Review process to ensure reconciliation of payroll charges to actual time records and rates. The organization will modify its calculations to ensure that pay rates are reflective of the timeframe in question (not for periods before or after). ECDI will update its calculations to include thresholds for Executive pay so they are not entered more than approved rates. The company is also exploring technology enhancements so that information from ECDI’s Payroll system flows directly into ECDI’s Accounting system to limit the chance of errors during extraction from Payroll system and uploading into Accounting system. Contact Person Responsible for Corrective Action: David Chew and Hudu Ahmed. Completion Date: In process
Common Origination & Disbursement Reporting Recommendation: We recommend the District evaluate its procedures and policies around reporting Pell disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disa...
Common Origination & Disbursement Reporting Recommendation: We recommend the District evaluate its procedures and policies around reporting Pell disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: Financial Aid Coordinators will monitor weekly to ensure matching of both systems. Responsible party: Financial Aid Coordinator and Administration Planned completion date for corrective action plan: April 1, 2026 Plan to monitor completion of corrective action plan: • The Financial Aid Coordinator will perform weekly reviews to confirm system alignment. • Administration will conduct quarterly oversight to ensure continued compliance and proper documentation.
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