Corrective Action Plans

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Finding 2026-002: Significant Deficiency – Enrollment Reporting Program: Student Financial Assistance Cluster – Federal Direct Loans and Pell Grants Assistance Listing Number (ALN): Various Federal Agency: U.S. Department of Education Federal Award Identification Number: Various Federal Award Year: ...
Finding 2026-002: Significant Deficiency – Enrollment Reporting Program: Student Financial Assistance Cluster – Federal Direct Loans and Pell Grants Assistance Listing Number (ALN): Various Federal Agency: U.S. Department of Education Federal Award Identification Number: Various Federal Award Year: June 30, 2026 Condition: For one of 25 students who were tested, the student’s withdrawal status was reported to NSLDS late, 71 days after the date of determination. For one of 25 students who were tested, the student’s graduation date was reported incorrectly to NSLDS. The College’s controls over enrollment reporting did not detect the errors. The sample was not a statistically valid sample. Corrective Action Plan Management agrees with the finding and is committed to strengthening its procedures to avoid similar issues in the future. Beginning in September 2026, a second and new Registrar’s Office staff member will be trained in to complete an additional review of the National Student Clearinghouse status for all students withdrawing after a particular semester. This secondary review will be completed at the end of January and at the end of June to ensure the 60-day reporting period is met. We will manually update the graduated enrollment status start date for the impacted student to the correct date through the National Student Clearinghouse. We will reach out to the National Student Clearinghouse to determine why the graduation date that was reported on the degree file does not match the date that was used when the student’s enrollment record was updated by the Clearinghouse using the graduated enrollment status from the degree verified process. Completion Date: November 1, 2026 Name(s) of Contact Person(s) Responsible for Corrective Action: Nathan Engle, Controller Email: Engle1@stolaf.com
2026-001 Period of Performance Corrective action planned: The organization will implement an additional step to review personnel cost categories that may have the potential of including out-of-period costs (e.g., performance bonus payments, contractual lump sum payments) and verify that these expens...
2026-001 Period of Performance Corrective action planned: The organization will implement an additional step to review personnel cost categories that may have the potential of including out-of-period costs (e.g., performance bonus payments, contractual lump sum payments) and verify that these expenses are allocated to the correct award cycle. If out-of-period transactions are identified, the organization will ensure that these expenses are allocated to unrestricted general operating funds. Anticipated completion date: October 2026 Contact person responsible for corrective action: Harjeet Sidhu, Chief Financial Officer
Finding #2026-002 – Allowable Costs – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Agriculture, Assistance Listing #10.932, Regional Conservation Partnership Program, Contract period: 06/12/24 – 12/31/26 Contract number: Supplemental-2983-A-1608, Co...
Finding #2026-002 – Allowable Costs – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Agriculture, Assistance Listing #10.932, Regional Conservation Partnership Program, Contract period: 06/12/24 – 12/31/26 Contract number: Supplemental-2983-A-1608, Contract period: 10/31/23 – 07/31/27 Contract number: Supplemental-2757-A-1212, Contract period: 08/29/23 – 03/31/26 Contract number: 917442230013, Passed through Sul Ross State University: Contract period: 04/01/25 – 03/31/26 Contract number: N/A. Condition and context: Of the $1,838,681 expended during the year ended March 31, 2026, approximately $1,729,640 related solely to the purchase of a conservation easement. The remaining expenditures of $109,041 consisted of payroll and related charges. In a sample of three payroll transactions tested, we noted in each case that reimbursement requests were based on hourly rates that exceeded the actual rates of pay of the employees performing the work, resulting in an overstatement of payroll charged to the grantors of $14,668. Recommendation: Develop policies and procedures to ensure that all costs charged to federal awards are based on actual costs incurred in accordance with federal award requirements. Planned corrective action: Management will establish procedures to ensure personnel costs charged to federal awards are based on actual allowable employee compensation and supported by appropriate time records. Federal reimbursement requests will be reviewed by the Director of Operations and the Director of Finance prior to submission to ensure that billed costs comply with federal award requirements. Management will also review the questioned costs identified in the audit and coordinate with the applicable grantor regarding any required repayment or adjustment. Responsible officer: Dina McIlhenny, Director of Finance and Brenna Gaik, Director of Operations. Estimated completion date: October 31, 2026.
NORTHWEST UNIVERSITY Corrective Action Plan For the Year Ended May 31, 2026 Finding Number 2026-001: Significant deficiency in internal controls over compliance with verification requirements. Significant deficiency in internal controls over compliance with verification requirements: For the two stu...
NORTHWEST UNIVERSITY Corrective Action Plan For the Year Ended May 31, 2026 Finding Number 2026-001: Significant deficiency in internal controls over compliance with verification requirements. Significant deficiency in internal controls over compliance with verification requirements: For the two students who received Pell grants of five total students selected for verification testing, verification status was not correctly coded in Common Origination and Disbursement (COD) system. This was the result of an issue in PFAIDS in which verification status code is only reporting for Pell recipients who were selected for verification by the FPS, not for students selected by the school. SFS has reviewed the scope of this issue and determined that these were the only two Pell recipients who were school-selected and verified, and the Verification Status Code for both students has been updated in COD as of 8/11. Contact Person(s): Cynthia Kennedy, Director of SFS; Ryan Porter, CFO; and Bernie Rundquist, Controller Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: The compliance issue was the result of a reporting error within the University’s current financial aid management system. Student Financial Services (SFS) is transitioning to a new financial aid management system in October 2026 and has ensured that the verification status flows correctly through COD reporting. The University goes live with the new system for the 2027-2028 award year. For the remainder of the current 2026-2027 reporting cycle, SFS has implemented a regularly scheduled manual review of COD reporting for students who are school-selected for verification to ensure correct reporting. This review will continue through the duration of processing in the current system. Anticipated completion date: October 2026
Return of Title IV (R2T4) Calculations Planned Corrective Action: The Financial Aid Office (FAO) has reviewed the R2T4 process and implemented additional procedures to strengthen the accuracy and documentation of withdrawal calculations, particularly for students enrolled in module-based programs. T...
Return of Title IV (R2T4) Calculations Planned Corrective Action: The Financial Aid Office (FAO) has reviewed the R2T4 process and implemented additional procedures to strengthen the accuracy and documentation of withdrawal calculations, particularly for students enrolled in module-based programs. The Financial Aid Office (FAO) has implemented the following enhanced procedures: • The internal R2T4 policy document has been reviewed for accuracy to ensure that all required steps are noted. • R2T4 calculations involving module enrollment, withdrawal exemptions, or Post-Withdrawal Disbursements will receive a second-level review before the calculation is finalized and funds are returned to the Department of Education. • The FAO will maintain a tracking process to monitor R2T4 calculations, required return amounts, and return deadlines to ensure that required returns are completed accurately and within the applicable federal timeframe. • The Financial Aid counselors will receive refresher training on R2T4 requirements, with particular emphasis on withdrawals from module-based programs, the 49% withdrawal exemption, Post-Withdrawal Disbursements, and determining which modules and aid must be included in the calculation. The Director of Financial Aid will periodically review a sample of completed R2T4 calculations to verify compliance with federal requirements and the institution's procedures. Any errors identified through this monitoring will be corrected promptly and used to determine whether additional staff training or procedural changes are necessary. Person Responsible for Corrective Action Plan: Cindi Patterson, Director of Financial Aid Anticipated Date of Completion: October 1, 2026
Need Analysis Planned Corrective Action: North Greenville University recognizes that this finding represents a recurrence of the prior-year need analysis finding. Although procedures were implemented after the prior finding, the current-year audit identified a specific gap in monitoring changes to t...
Need Analysis Planned Corrective Action: North Greenville University recognizes that this finding represents a recurrence of the prior-year need analysis finding. Although procedures were implemented after the prior finding, the current-year audit identified a specific gap in monitoring changes to the Cost of Attendance (COA) and their impact on subsidized loan eligibility. The enhanced procedures described below address this risk by identifying instances where a student's subsidized loan exceeds remaining financial need after changes to COA. The Financial Aid Office (FAO) has implemented the following enhanced procedures: • The FAO has developed a targeted PowerFAIDS report to identify students whose subsidized loan award exceeds their remaining financial need. The report will be used as a specific exception report to identify potential subsidized loan over-awards resulting from changes to a student's financial aid eligibility. • The targeted PowerFAIDS report will be reviewed as part of the FAO’s pre-disbursement compliance process. Student records identified by the report will be reviewed to determine whether a change in COA, enrollment, or other financial aid resulted in a subsidized loan over-award. • The Financial Aid staff responsible for packaging, COA adjustments, loan adjustments, and disbursement review will receive additional guidance regarding the relationship between COA, remaining need, and subsidized loan eligibility. Staff will be specifically instructed to reevaluate loan eligibility when changes to housing status or other components of COA affect a student's remaining need. The PowerFAIDS exception report identifying subsidized loan awards that exceed remaining financial need will be reviewed each term and as part of the pre-disbursement review process. Additionally, the FAO will monitor significant changes to COA, particularly housing status changes, to ensure that changes in need are appropriately reflected in federal loan eligibility. Any exceptions identified will be reviewed and corrected promptly. Documentation of the review and any resulting adjustments will be retained as evidence of the control being performed. Regarding the one locked student record identified, PowerFAIDS currently has a task that identifies students in DR (Data Review) status and assigns the record to a Financial Aid counselor for review. As an enhancement to this existing control, counselors will verify the student's ISIR processing status and confirm that applicable ISIR fields are unlocked when an updated ISIR is expected. This additional verification is intended to ensure that a subsequent ISIR can successfully upload and update the student's financial aid record. Counselors will review the student's record to determine whether the locked ISIR prevented updated FAFSA information from being received or processed and will take the appropriate corrective action before finalizing the student's eligibility. As part of the DR review, counselors will verify that the student's most recent ISIR has processed correctly and that applicable federal aid eligibility, including Pell Grant eligibility, has populated appropriately. If the student's record remains in DR because of an ISIR processing issue, the counselor will resolve the issue and document the review before the student's aid is finalized. Person Responsible for Corrective Action Plan: Cindi Patterson, Director of Financial Aid Anticipated Date of Completion: October 1, 2026
Student Financial Assistance Cluster– Assistance Listing Nos. 84.268 Recommendation: We recommend Augsburg University implement controls to ensure that disbursement dates reported to COD are aligned with the actual date funds are credited to the student’s account. This could include system controls ...
Student Financial Assistance Cluster– Assistance Listing Nos. 84.268 Recommendation: We recommend Augsburg University implement controls to ensure that disbursement dates reported to COD are aligned with the actual date funds are credited to the student’s account. This could include system controls that delay COD reporting until disbursements are fully processed or periodic reconciliations between COD records and the student ledger to identify and correct discrepancies in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Financial Services will conduct bi-weekly reconciliations between COD records and the student ledger to identify and correct any discrepancies. Name(s) of the contact person(s) responsible for corrective action: Catherine Maun Planned completion date for corrective action plan: May 31, 2027
All staff responsible for registration and income verification in all service lines, programs, and sites received training on income eligibility assessment, documentation, and application in October of 2025. Chart Auditing and Staff Coaching and Corrective Action: ▪ Annual competency assessments for...
All staff responsible for registration and income verification in all service lines, programs, and sites received training on income eligibility assessment, documentation, and application in October of 2025. Chart Auditing and Staff Coaching and Corrective Action: ▪ Annual competency assessments for all registration staff in all service lines, programs, and sites will be part of clinical compliance training between January 1 and February 28, 2027. Competency assessment includes eligibility assessment, documentation, and application. Failure to complete the assessment in the assigned time or failure to complete the assessment successfully will result in letter of expectation with 14 days to demonstrate improvement, followed by formal disciplinary action in the form of a verbal reprimand and 14 business days to remediate before a written reprimand is issued. Completion date for action: 03/31/2027 ▪ Conducting random audits of 2 percent of patients with a visit in a calendar month across all service lines and programs, or a minimum of 90 charts with a standard audit tool that provides scoring to prompt coaching and additional training for staff who fail to meet a 90% benchmark. Completion date for action: On-going. Will have full 2% compliance by 10/31/2026 ▪ Develop automated audit tool that provides real-time feedback on all patient registration records for consistency and accuracy of SFDS screening and documentation. Completion date for action: 12/31/2026 ▪ Work with OCHIN to allow SFDS and income verification in one service line to flow into accounts for all service lines to mitigate issues stemming from different FPLs depending on service line. Completion date for action: 12/31/2026 Contact person: Angela Hurley, Director of Operations Completion date for action: 03/31/2027
View of Responsible Officials The University agrees with the findings and recommendation. Management reviewed the identified exceptions and determined they resulted from the use of incorrect institutional charges and failure to exclude a scheduled break of five or more consecutive calendar days in c...
View of Responsible Officials The University agrees with the findings and recommendation. Management reviewed the identified exceptions and determined they resulted from the use of incorrect institutional charges and failure to exclude a scheduled break of five or more consecutive calendar days in certain Return of Title IV calculations. The University has implemented enhanced procedures to validate institutional charges, identify and exclude qualifying scheduled breaks, provide additional staff training, and require secondary review of Return of Title IV calculations.
Verification Planned Corrective Action: Mid-America Christian University has updated its verification policies and procedures to ensure proper collection, review, and retention of secondary tax documentation. For students whose Federal Tax Information (FTI) cannot be retrieved via the Direct Data Ex...
Verification Planned Corrective Action: Mid-America Christian University has updated its verification policies and procedures to ensure proper collection, review, and retention of secondary tax documentation. For students whose Federal Tax Information (FTI) cannot be retrieved via the Direct Data Exchange (FA-DDX) or whose data is incomplete/unverified, Financial Aid Counselors are required to obtain and retain official IRS Tax Return Transcripts or signed tax returns prior to finalizing aid eligibility. The Financial Aid staff has received comprehensive training on FA-DDX exception handling and acceptable secondary documentation. To ensure ongoing accuracy, the Financial Aid Director (or designee) will perform a 100% Quality Assurance (QA) secondary review of all completed verification files prior to disbursement during the initial rollout phase, transitioning to a structured random sampling protocol once error rates remain at zero. A formal Quality Control Checklist has been incorporated into the operational workflow. Person Responsible for Corrective Action Plan: Tammy Comalander, Interim Director of Financial Aid Anticipated Date of Completion: 07/01/2026
Common Origination and Disbursement (COD) Reporting Planned Corrective Action: Mid-America Christian University (MACU) has revised its Title IV disbursement and ledger posting workflow to ensure alignment between internal financial records and Common Origination and Disbursement (COD) reporting. Pre...
Common Origination and Disbursement (COD) Reporting Planned Corrective Action: Mid-America Christian University (MACU) has revised its Title IV disbursement and ledger posting workflow to ensure alignment between internal financial records and Common Origination and Disbursement (COD) reporting. Previously, student ledger postings were dated using the G5 deposit date rather than the COD disbursement date. To resolve this issue and prevent future recurrence: 1. Alignment of Disbursement Dates: MACU has updated its workflow in PowerFAIDS and the Jenzabar to ensure disbursements are posted to student accounts using the disbursement date reported to COD rather than the /G5 drawdown/deposit date. 2. Timely COD Reporting: Actual disbursement records generated in PowerFAIDS will be transmitted to the COD System within 15 calendar days of the actual disbursement date, in full compliance with 34 CFR 668.164. 3. Reconciliation & Controls: The Financial Aid Office and Bursar Office will perform a monthly three-way reconciliation between G5 drawdown records, PowerFAIDS disbursement data (alongside student ledgers), and COD actual disbursement records to guarantee date consistency and compliance across all systems. Person Responsible for Corrective Action Plan: Bobbie Spurgeon-Harris, Executive Vice-President and Chief and Dean Meadows, VP / CFO Anticipated Date of Completion: 10/01/2026
2026-002 – Deposits in excess of FDIC insured limits Corrective action planned: Appleway Court 202 will review the current deposit situation and related FDIC coverage and split cash deposits between multiple banks or work with our current bank to ensure that amounts in excess of FDIC limits are full...
2026-002 – Deposits in excess of FDIC insured limits Corrective action planned: Appleway Court 202 will review the current deposit situation and related FDIC coverage and split cash deposits between multiple banks or work with our current bank to ensure that amounts in excess of FDIC limits are fully insured and collateralized. Anticipated completion date: May 31, 2027 Contact person responsible for corrective action: Charles Wells, CFO
2026-005 Special Tests and Provisions Corrective action planned: In December 2025, responsibility for administration of the Sliding Fee Discount Program (SFDP) was transferred from the COO to the CFO/DFO. Several upgrades in tools used for determinations, reporting, and quality assurance were immedi...
2026-005 Special Tests and Provisions Corrective action planned: In December 2025, responsibility for administration of the Sliding Fee Discount Program (SFDP) was transferred from the COO to the CFO/DFO. Several upgrades in tools used for determinations, reporting, and quality assurance were immediately instituted. OMC review now includes electronic calculations of income, and several instances of documenting the SFDP appear on the application. Furthermore, each application package now includes a copy of the OMC Federal Poverty Level sliding scale with the determination clearly marked on the form. OMC’s SFDP Scales are also displayed in the lobby area and other visible areas at all OMC sites. Finally, the CFO/DFO performs a quarterly audit of all applications entered in that quarterly period. Each application is reviewed for completeness, and each participant’s account is reviewed for proper application of the SFDP. Any findings are corrected immediately and reported to the Quality Assurance committee so methods can be developed to prevent future errors. Anticipated completion date: 12/31/2025 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
2026-003 Period of Performance (repeat of finding 2025-003) Corrective action planned: The former CEO of OMC did not understand Generally Accepted Accounting Principles and, specifically, Accrual Accounting. He did not allow the Accounting Department to make accrual entries monthly. At the beginning...
2026-003 Period of Performance (repeat of finding 2025-003) Corrective action planned: The former CEO of OMC did not understand Generally Accepted Accounting Principles and, specifically, Accrual Accounting. He did not allow the Accounting Department to make accrual entries monthly. At the beginning of FY 2026 - 2027, the CFO/DFO required the accrual of payroll each month to accurately reflect the personnel expense of OMC. OMC accounting staff will utilize the Sage Impact® Accounting System to accrue other expenses that were incurred in the period but not yet paid, so that only cost for goods and/or services incurred within the approved budget period are reflected accurately in monthly financial reporting and costs are not allocated outside the budget period. The CFO/DFO has developed an accrual template so that utility bills that cross periods, such as one example in this report, are properly accounted for and allocated to the correct period. This will also be monitored by the external independent financial consultant and the CEO who is a degreed accountant. Anticipated completion date: 08/31/2026 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will ...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will be in compliance with Uniform Guidance to ensure proper annual monitoring. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification for suspension and debarment prior to entering into a transaction/contract. With annual review of suspension and debarment throughout the program lifecycle. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCAA will implement a formal year-end close communication process for vendors and subrecipients. Fiscal year-end reminders will be distributed by email,...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCAA will implement a formal year-end close communication process for vendors and subrecipients. Fiscal year-end reminders will be distributed by email, with a request that final invoices be submitted before the books are closed. PCAA will also maintain the books open for six weeks after fiscal year-end to help ensure expenditures are recorded in the proper fiscal year. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: CFO will be approving CEO timesheets Name(s) of the contact person(s) responsible for corrective action: Mary Lubben, CFO Planned completion date for co...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: CFO will be approving CEO timesheets Name(s) of the contact person(s) responsible for corrective action: Mary Lubben, CFO Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
SIGNIFICANT DEFICIENCY Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required ...
SIGNIFICANT DEFICIENCY Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond coverage was increased prior to fiscal yearend on 05/29/2026 following an internal review that showed that soaring revenues had outpaced the previously enacted increased coverage. The policy has been updated to review the monthly revenue to be sure there is sufficient minimum Fidelity Bond coverage prospectively. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa, Executive Director, Berkshire Retirement Home, Inc. DBA Berkshire Place, 290 South Street, Pittsfield, MA 01201 413-445-4056 #160; eforfa@berskhireplace.com Planned completion date for corrective action plan: 05/29/2026
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-e...
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2026, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training cont...
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training controls over the application of the sliding fee discount schedules. The Director of Patient Services (or designee) will perform monthly audits of 25 randomly selected patients accounts that received a sliding fee discount to verify that the correct discount schedule was applied and that the patient responsibility was calculated accurately. In addition, for any future changes to the sliding fee discount schedule, management will implement a transition review process that includes: • Verification that the updated fee schedule is accurately loaded into the billing system prior to the effective date and old fee schedules are inactivated. • Additional training for billing staff before implementation of any revised sliding fee schedule. • Continued monthly audits of sliding fee discounted patient accounts. • Quarterly reporting of audit results to Chief Financial Officer, to identify recurring issues and ensure corrective actions taken are effective. Anticipated completion date: July 31, 2026
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