Corrective Action Plans

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RHC of NEPA has taken significant steps to improve and rectify their sliding fee deficiency over its last 3 audits. RHC of NEPA has improved from 2 consecutive material weakness findings to having substantial improvement and reduced its status to a significant deficiency. It is important to note tha...
RHC of NEPA has taken significant steps to improve and rectify their sliding fee deficiency over its last 3 audits. RHC of NEPA has improved from 2 consecutive material weakness findings to having substantial improvement and reduced its status to a significant deficiency. It is important to note that 2 of the outstanding claims identified had timely sliding fee documents completed, however they were out of compliance due to human error of calculation of the sliding fee percentage. Education and internal audits which were implemented throughout the organization which have driven the marked improvement will continue to be disseminated throughout the organization. Clearly based on the improvement that has occurred, current processes and level of attention are the correct items to rectify and become fully compliant with sliding fee requirements. These policies will be the focus of additional training with a separate session being dedicated to the updated sliding fee implementation in February of 2026.
Views of Responsible Officials and Corrective Action Plan During Fall 2024, the Financial Aid Office experienced the departure of two key senior staff members who were primarily responsible for Return to Title IV (R2T4) processing and the reversal of federal funds. As a result, new staff were tempor...
Views of Responsible Officials and Corrective Action Plan During Fall 2024, the Financial Aid Office experienced the departure of two key senior staff members who were primarily responsible for Return to Title IV (R2T4) processing and the reversal of federal funds. As a result, new staff were temporarily assigned to manage these responsibilities during the transition period, which contributed to delays in returning funds within the required regulatory timeframe. A comprehensive review of all R2T4 calculations completed during the 2024–2025 aid year determined that records processed prior to mid-November 2024 had over awarded funds returned within the applicable 45- and 30-day regulatory timeframes. This timeframe aligns with the period when the responsible staff members announced their retirements. To resolve this matter and prevent recurrence, the District has implemented the following corrective measures. Targeted R2T4 Training: Staff responsible for Return to Title IV (R2T4) processing and disbursement reversals are in the process of completing the National Association of Student Financial Aid Administrators (NASFAA) R2T4 credential training. This certification will ensure staff possess consistent, up-to-date knowledge of federal requirements around the R2T4 process to include the timelines required to return over-awarded funds to the department. Automated Monitoring Report: A recurring monitoring report has been established to identify students with pending Returns of Title IV (R2T4) funds. The report automatically flags cases exceeding 30 days and, for students who withdrew prior to the start of the term, those exceeding 20 days. Department managers will generate and review this report on a weekly basis to ensure timely compliance with federal return requirements. In instances where pending returns are identified as being past the alert threshold, Financial Aid management will promptly coordinate with Fiscal Services to expedite the return of funds and document resolution actions. Cross-Training for Continuity of Operations: Ongoing cross-training has been implemented among Financial Aid staff to ensure sufficient coverage during vacations, extended leaves, or unexpected absences. At least two designated staff members will be fully trained and authorized to perform R2T4 calculations and return processing to prevent delays in compliance during personnel transitions. These measures strengthen accountability, monitoring, and collaboration between the Financial Aid and Fiscal Services departments to ensure full compliance with federal cash management and return regulations.
Finding Number: 2025-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2026 Responsible Contact Person: Dave Massa, Treasurer
Finding Number: 2025-001 Planned Corrective Action: Towpath Trail High School will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 2/14/2026 Responsible Contact Person: Dave Massa, Treasurer
Finding 2025-001: Reportable finding considered a significant deficiency – Activities Allowed and Unallowed Management at Satellite Affordable Housing Associates Property Management (“SAHA PM”) is in agreement with the finding and intends to follow the requirements of the HUD Regulatory Agreement in...
Finding 2025-001: Reportable finding considered a significant deficiency – Activities Allowed and Unallowed Management at Satellite Affordable Housing Associates Property Management (“SAHA PM”) is in agreement with the finding and intends to follow the requirements of the HUD Regulatory Agreement in the future. Management has reimbursed the property $28,539, an amount equal to HCD’s net cash flow payment from FY 2024. Management will reimburse the property the $12,600 for FY 2025 and FY 2024 annual monitoring fees paid to HCD. Management will seek to obtain HUD approval on form HUD-9250 for payment of these fees from residual receipts.
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should implement a strategy of using time and effort documentation in determining payroll costs charged to grants, including use of backward-looking reconciliations when necessary. Explanation of disagreement with a...
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should implement a strategy of using time and effort documentation in determining payroll costs charged to grants, including use of backward-looking reconciliations when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management of the Organization is in the process of implementing a policy to track time and effort of all employees based on actual time spent by grant. Some employees work directly with tenants on a HUD funded grant on a regular basis, but all employees may work directly with a tenant on a HUD funded grant or may perform administrative work specifically on a HUD funded grant from time to time. Therefore, all employees will track time spent with tenants or specifically with a grant in the Yardi Tenant Contact system. • Housing Support Staff and Management will document grant allocations as required. • Backoffice employees, such as those working in HR or Accounting, will be allocated to Admin and Support within the HUD funded grant, based on time spent. • Maintenance employees can be allocated to tenants based on units and work orders. • Formal review of payroll and grant allocations, based on time sheets, will take place by March 30th 2026, and on a monthly basis going forward. Potential true-up to take place after each review. Name(s) of the contact person(s) responsible for corrective action: Susan Keshen, Fractional CFO Planned completion date for corrective action plan: March 31, 2026
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should strengthen internal controls to ensure timely updates of tenant subsidy amounts based on the contract terms and implement a review process to verify that HAP payments align with the most recent annual contrac...
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should strengthen internal controls to ensure timely updates of tenant subsidy amounts based on the contract terms and implement a review process to verify that HAP payments align with the most recent annual contract documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management of the Organization has established a system of internal control monitoring and review to ensure HAP payments align with the most recent annual contract documentation. Compliance Officer reviews annual reports for all clients every month. Spreadsheet is reviewed for variance and adjustments made as needed. Name(s) of the contact person(s) responsible for corrective action: Susan Keshen, Fractional CFO Planned completion date for corrective action plan: August 31, 2025.
Finding 2025-001: Significant deficiency in internal controls over compliance and immaterial noncompliance Corrective Action Planned: Connected Lane County updated internal control processes, approved by the board on 05.21.25, which significantly reduced year end processing delays and the number of ...
Finding 2025-001: Significant deficiency in internal controls over compliance and immaterial noncompliance Corrective Action Planned: Connected Lane County updated internal control processes, approved by the board on 05.21.25, which significantly reduced year end processing delays and the number of corrections needed to complete the audit. The audit for fiscal year 2025 ending on June 30, 2025 was completed within seven months of the end of the fiscal year. Person(s) Responsible: Jesse Nelson, Executive Director and Mary Bell, Finance Manager Anticipated Completion Date: 09.01.2025
Finding 1172539 (2025-002)
Material Weakness 2025
Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement controls for review of payment limits prior to distributing funds to program participants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...
Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement controls for review of payment limits prior to distributing funds to program participants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is implementing a tool to monitor and track the incentive payments. Name(s) of the contact person(s) responsible for corrective action: David Oppenlander, CFO Planned completion date for corrective action plan: January 31, 2026
Finding 1172537 (2025-001)
Material Weakness 2025
Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement a strategy of using time and effort documentation in determining payroll costs charged to grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...
Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement a strategy of using time and effort documentation in determining payroll costs charged to grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in the process of implementing a policy to track time and effort of salaried employees. Name(s) of the contact person(s) responsible for corrective action: David Oppenlander, CFO Planned completion date for corrective action plan: January 31, 2026
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 student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement w...
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 student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar’s Office has put in place steps to ensure that any exception reports from the Clearinghouse are immediately reviewed and any exceptions are addressed and resubmitted. In addition, the Registrar’s Office has put in place steps to ensure that students are submitted to the Clearinghouse early enough so that they will still be submitted by the Clearinghouse to NSLDS timely, even if there are delays by the Clearinghouse. Name(s) of the contact person(s) responsible for corrective action: Kristin Dvorak, University Registrar; Kevin Moenkhaus, Associate Registrar Planned completion date for corrective action plan: January 2026
Finding 2025-001 Required Disclosures Views of Responsible Officials The University agrees with the auditor’s findings and recommendations. Corrective Action Plan The University has participated in educational opportunities provided by the Department of Education and implemented procedures to ensure...
Finding 2025-001 Required Disclosures Views of Responsible Officials The University agrees with the auditor’s findings and recommendations. Corrective Action Plan The University has participated in educational opportunities provided by the Department of Education and implemented procedures to ensure timely disclosure. All subsequent updates have been completed. Implementation Date Immediate Individual(s) Responsible Brandon Goen, Controller
Noncompliance with Enrollment Status Change Reporting. Auditor Description of Condition and Effect. Of 18 enrollment status changes tested, we noted 1 change that was not reported to the National Student Loan Data System (NSLDS) within 60 days due to a student being assigned a different coding struc...
Noncompliance with Enrollment Status Change Reporting. Auditor Description of Condition and Effect. Of 18 enrollment status changes tested, we noted 1 change that was not reported to the National Student Loan Data System (NSLDS) within 60 days due to a student being assigned a different coding structure within the College's system which resulted in the student being excluded from the standard status-change reporting process. As a result of university personnel using the incorrect semester start dates. As a result of this condition, the College was temporarily out of compliance with enrollment reporting requirements. Auditor Recommendation. We recommend the College review and update its enrollment reporting processes to ensure that all students-including those with unique or foreign-student coding-are captured in routine status-change monitoring and NSLDS reporting procedures. The College should implement controls to detect nonstandard coding and ensure that all enrollment changes are identified and reported within required federal timelines. Corrective Action. Bay College took swift action after determining some students were being excluded in our enrollment reporting. Our reporting process was excluding students who were noted as being a citizen of a foreign county. We now review these students prior to each reporting cycle to determine if they should be included in the reporting. The Financial Aid team reviews this report to determine if the student is eligible for federal student aid. Students who are eligible are indicated and provided to the Institutional Effectiveness team to include in the enrollment reporting. This process is completed prior to each reporting cycle. For students who were not included in our prior reporting, the Financial Aid team working directly with the Institutional Effectiveness team, determined which should be reported and completed their enrollment reporting directly through NSLDS. Responsible Person. Ruth Carlson, Director of Financial Aid. Anticipated Completion Date. June 30, 2026
Finding 2025-002: Allowable cost-Significant deficiency in internal controls over compliance. Management Response The District purchased supplies on the District credit card. There was no purchasing requisition entered or approval prior to making the purchase. The District conducted procurement trai...
Finding 2025-002: Allowable cost-Significant deficiency in internal controls over compliance. Management Response The District purchased supplies on the District credit card. There was no purchasing requisition entered or approval prior to making the purchase. The District conducted procurement training in August 2025. The District will conduct another training in October 2025 to discuss procurement requirements regarding credit card purchases. If a credit card purchase is made without a requisition, the accounts payable staff will notify the management prior to the credit card payment.
Finding 2025-001: Reporting – Significant deficiency in internal controls over compliance. Management Response: The District’s Child Nutrition Assistant Director (AD) prepared the claims data submitted into the Tx-UNPS System to receive Child Nutrition federal funding. The claims data was submitted ...
Finding 2025-001: Reporting – Significant deficiency in internal controls over compliance. Management Response: The District’s Child Nutrition Assistant Director (AD) prepared the claims data submitted into the Tx-UNPS System to receive Child Nutrition federal funding. The claims data was submitted without management approval. The District will implement procedures to ensure that monthly claim reports are reviewed by the Chief Operations Officer (COO) prior to being submitted into Tx-UNPS System. The AD will prepare the claims report documentation, which includes the point of sale and attendance reports. The claims report and supporting documentation will be emailed to the COO. Once the reports are reviewed and determined to be accurate, the COO will email approval. Once the AD receives approval via email from the COO, the email will be printed or digitally saved with the claims reports. The AD will submit claims data into the Tx-UNPS System and print the NSLP Claim for Reimbursement Summary. The Summary will be sent to the COO for confirmation. The new process will begin in October 2025.
Views of Responsible Officials and Corrective Action Plan The Campus Business and Financial Aid Offices reviewed the untimely return of Title IV (R2T4) funds and implemented a revised process to ensure compliance. Weekly R2T4 reviews: Financial Aid specialists now review all accounts requiring R2T4 ...
Views of Responsible Officials and Corrective Action Plan The Campus Business and Financial Aid Offices reviewed the untimely return of Title IV (R2T4) funds and implemented a revised process to ensure compliance. Weekly R2T4 reviews: Financial Aid specialists now review all accounts requiring R2T4 calculations each week. Mid-month reconciliation: Added to the existing end-of-month process to expedite fund returns. Weekly coordination meetings: Financial Aid and Business Services staff review pending cases to ensure all returns meet the 45-day federal deadline. Quarterly compliance checks: Other Financial Aid staff monitor adherence and make recommendations for process improvement. The District will review this process each term and adjust procedures as needed to sustain compliance and efficiency.
As a 501c3 non-profit organization with a large portfolio of federally funded cost-reimbursement awards, management of cash is of fundamental importance due to the nature of the business and floating of cash involved in base operations and maintaining our valued vendor partnerships. Parallax has mad...
As a 501c3 non-profit organization with a large portfolio of federally funded cost-reimbursement awards, management of cash is of fundamental importance due to the nature of the business and floating of cash involved in base operations and maintaining our valued vendor partnerships. Parallax has made significant improvements from prior years, including but not limited to, establishment of a formal Billing Policy and substantially fewer selections where vendor payment wasn’t made within 30 days of Parallax’s request for reimbursement from the government. Unfortunately, Parallax encountered some cumulative timing challenges on cash collections because of provisional vs. anticipated final billing rates in fiscal year 2025. Parallax is also in the process of renegotiating the terms of the line of credit that would avoid fluctuations based on receivables. We believe a combination of internal controls through the policy put in place, collection of backlog rate variances and a static line of credit availability will collectively assist with ensuring future compliance. The anticipated completion date of May 1, 2026 was derived from the requirement to submit our Incurred Cost Submission to the government by December 31, 2025. The anticipated completion date assumes established final rates within a 60-calendar day window of that date to allow time to process billings, communicate with clients and allow time for payment processing to Parallax.
Subject: Management response to Fiscal Year 2025 Audit Findings The management of Village Tech Schools acknowledges receipt of the following findings for the FY25 audit and has developed a corrective action plan response to address the findings. Finding 2025-001: Reporting – Significant deficiency i...
Subject: Management response to Fiscal Year 2025 Audit Findings The management of Village Tech Schools acknowledges receipt of the following findings for the FY25 audit and has developed a corrective action plan response to address the findings. Finding 2025-001: Reporting – Significant deficiency in internal controls over compliance. Management Response: The District’s Child Nutrition Supervisor (CNS) prepared the claims data submitted into the Tx-UNPS System to receive Child Nutrition federal funding. The claims data was submitted without management approval. The District will implement procedures to ensure that monthly claim reports are reviewed by the Chief Operations Officer (COO) prior to being submitted into Tx-UNPS System. The CNS will prepare the claims report documentation, which includes the point of sale and attendance reports. The claims report and supporting documentation will be emailed to the COO. Once the reports are reviewed and determined to be accurate, the COO will email approval. Once the CNS receives approval via email from the COO, the email will be printed or digitally saved with the claims reports. The CNS will submit claims data into the Tx-UNPS System and print the NSLP Claim for Reimbursement Summary. The Summary will be sent to the COO for confirmation. The new process will begin in October 2025.
R2T4 Audit: FY25 Corrective Action Plan To address the audit findings, the FCC has initiated the following actions: •Spring 2025, Completed: oRevised Processing Timeline: All R2T4 calculations and returns are now completedwithin 30 days, reserving the final 15 days exclusively for QA. (Responsible L...
R2T4 Audit: FY25 Corrective Action Plan To address the audit findings, the FCC has initiated the following actions: •Spring 2025, Completed: oRevised Processing Timeline: All R2T4 calculations and returns are now completedwithin 30 days, reserving the final 15 days exclusively for QA. (Responsible Leader:Director of Financial Aid) oCross-Training and Succession Planning:Staff cross-trained; onboarding/offboardingdutiesdocumented to eliminate single points of failure.(Responsible Leader: Director ofFinancial Aid) •September 2025, Underway: oLeadership Communication Protocol:A formal process is beingfinalized to ensurecompliance issues are documentedand escalatedforawareness to the President and theCFO/VP for Administration. Thisprotocol alsoreinforcesa cultureof accountability where compliance concernsare escalated promptly and transparently. (ResponsibleLeader: AVP for Student and Financial SupportServices) •Monthly Monitoring and Reporting:Compliance reviews reported monthlyto the VP for Student Experience and then to the President and the CFO/VPfor Administration for awareness. (Responsible Leader: VP for StudentExperience). oQA Tracking Form: Implemented to document each review and correction for auditverification. (Responsible Leader: Director of Financial Aid) •Fall 2025 – Spring 2026, To Be Planned and Executed: oExternal Program Review: FCC will engage an external consultant agency (TBD) toconduct a comprehensive Financial Aid Office program review in FY26, validatingcompliance, staffing adequacy, and process integrity. (Responsible Leader: AVP forStudent and Financial Support Services) •Timeline, Next Steps, Responsible FCC Leader: oOctober 6, 2025: Submit formal corrective action plan to Auditors (VPSE) oOctober 15, 2025: Receive first compliance review report for AVP to VP reporting toPresident’s Council, as part of enterprise risk management awareness. (AVP/VPSE) oJanuary to April 2026: Conduct external program review of the Financial Aid Office andreport findings to President and the CFO/VP for Administration by June 2026. (AVP) •Expected completion date: June 2026 •Person responsible: Dr. Edmund T. Cabellon, Interim Vice President for Student Experience
Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. Finding 2025-001 – Maintenance of Effort (MOE) Federal Program: Title I, Part A (84.010) Repeat Finding: Yes (Prior Audit Finding 2024-004) Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. acknowledges the Maintenan...
Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. Finding 2025-001 – Maintenance of Effort (MOE) Federal Program: Title I, Part A (84.010) Repeat Finding: Yes (Prior Audit Finding 2024-004) Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. acknowledges the Maintenance of Effort (MOE) finding related to the accuracy of expenditures reported on the Form 9 cash-basis report submitted to the Indiana Department of Education (IDOE). This finding is a repeat finding from the prior audit period. The School recognizes that prior corrective actions were not sufficient to fully address the reliability of Form 9 reporting. As a result, the School has enhanced and formalized internal controls surrounding Form 9 preparation, review, and submission to ensure compliance with IDOE guidelines and to prevent recurrence of this issue. Corrective Actions Implemented 1. Formal Form 9 Reconciliation Process ○ The School has implemented a documented reconciliation process to compare internal cash-basis financial records to the Form 9 prior to submission. ○ This reconciliation ensures that only allowable cash expenditures are reported and that reported totals align with bank activity and supporting documentation. 2. Strengthened Review and Approval Controls ○ Preparation of the Form 9 is now subject to a multi-level review process. ○ The Form 9 will be reviewed by the School’s financial consultant and School leadership to confirm accuracy, compliance with IDOE reporting guidance, and consistency with underlying financial records prior to submission. 3. Written Procedures and Staff Training ○ Written internal procedures have been developed outlining Form 9 preparation requirements, including proper treatment of accruals, timing differences, and non-cash items. ○ Staff involved in financial reporting have received refresher training on IDOE Form 9 reporting requirements and maintenance of effort considerations. 4. Ongoing Monitoring and Communication ○ The School will perform periodic internal monitoring of cash-basis expenditures throughout the fiscal year to identify potential discrepancies prior to year-end reporting. ○ When necessary, the School will proactively communicate with IDOE to clarify reporting requirements before submission. Responsible Officials ● Board of Directors ● School Leadership ● Director of Finance Planned Completion Date ● Immediate and Ongoing These procedures have been implemented and will be applied to the current and all future reporting periods. Expected Results The implementation of these enhanced internal controls will ensure that Form 9 expense reporting is accurate, complete, and prepared in accordance with IDOE guidelines. This will support reliable Maintenance of Effort calculations by IDOE and is expected to prevent recurrence of this finding in future audit periods. Don Stewart COO Matchbook Learning
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar tha...
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar that the entire Finance staff reviews at every biweekly Finance meeting, but the WIFIA deadlines were errantly not incorporated into that tool until January 2026. While management agrees with the finding, it should be noted that management was not operating without controls. Rather, the deadline being adhered to was just the wrong date. Management submitted updated financial model/plan by January 31, 2025, which was within the month following the close of the calendar year, similarly to the quarterly construction reports that are due 30 days after the end of the preceding quarter. In addition, the data on the annual model reflected current information near the time of release of the report, not June 30, 2024. So, in substance, management provided an even more current, relevant document. Management acknowledges the additional finding language that the June 30, 2025 quarterly construction monitoring report was submitted on day 31 rather than day 30 following the close of the quarter. Finally, management acknowledges that the annual updated financial model/plan for June 30, 2025, will be submitted in January 2026 as the internal control, as mentioned above, was not corrected until January 2026, which will result in the same finding on the Single Audit for June 30, 2026. However, management believes that we have taken the appropriate measures required to avoid ongoing replication. Responsible Official: Matt Zook, Finance Director
a. Significant Deficiency - Condition: We noted in our testing of Twenty-First Century reimbursement that claims were not being reviewed before being submitted. B. Plan of action - The responsible officials recognize the need for an improved review process to ensure grant claims are accurate and pro...
a. Significant Deficiency - Condition: We noted in our testing of Twenty-First Century reimbursement that claims were not being reviewed before being submitted. B. Plan of action - The responsible officials recognize the need for an improved review process to ensure grant claims are accurate and properly documented. To address this deficiency, the following actions will be implimented: Role assignment: The Business Manager will prepare and submit each federal grant claim, and the fiscal assistant will conduct a review before final submission. This role assignment will ensure both preparation and indeprendent review are in place. c. Timeline for implimentation: New procedures will be established within the fiscal quarter, with training and full implmentation scheduled by 3/1/2026.
Bethany College and Affiliate Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025‐001 – Significant Deficiency in Internal Control Over Compliance – Return of Title IV Funds Condition Found: Four students who had withdrawn from the institution did not have Title IV funds returned to...
Bethany College and Affiliate Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025‐001 – Significant Deficiency in Internal Control Over Compliance – Return of Title IV Funds Condition Found: Four students who had withdrawn from the institution did not have Title IV funds returned to the Department of Education within 45 days. Corrective Action Plan: The College will review our workflow and make oversight improvements to prevent future delays, including standardizing withdrawal notification and handoff procedures, initiating R2T4 calculations immediately upon withdrawal determination, confirming that required COD adjustments are submitted without delay and establishing internal tracking to monitor return activity against the 45 day requirement. Responsible Official for Corrective Action Plan: Sarah Sherinian, Vice President for Student Success & Operational Excellence/Chief Financial Aid Officer
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance – Reporting Finding 2025-010 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of...
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance – Reporting Finding 2025-010 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Per 2 CFR 200.334 the recipient must retain all federal award records for three years from the date of submission of their final financial report. Condition: During the audit we tested 9 reports and noted the following: a) There was one (1) instance out of (9) nine reports tested where the submitted reports were unable to be provided, including the date of submission for the reports. b) There were four (4) instances out of nine (9) reports tested where the County was unable to provide evidence the report was reviewed prior to submission. c) There were two (2) instances out of nine (9) reports tested where the County was unable to provide the date of submission for the reports. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: By not having the required documentation and underlying support, the County is not able to demonstrate compliance with the applicable requirements. Cause: The County did not have a formal policy to ensure documentation was retained to evidence review and submission of all reports. Recommendation: While the County made updates to policies and procedures surrounding reporting during the current year to address the prior year finding, the County should ensure these policies are adhered to ensure all submitted reports and underlying data are retained in accordance with the Uniform Grant Guidance requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: As of July 2025, The Health Department has created and adopted policy FIS-05 Retention of Reporting Requirement Submissions to ensure that federal award reports and data are retained in accordance with Uniform Guidance. The Health Department will document with screen shots as outlined in the FIS-05 Policy, to address circumstances when the required report consists of answering a NCDHHS survey or form that does not have “save” or “download” capability, to maintain record of documented submissions. In addition, the Health Department has developed a standard operating procedure whereby fiscal compliance Management Analysts, in collaboration with Program Managers, ensure they have reviewed federal award reports prior to submission and file documentation of review and approvals. While review of grant reports is common, the Health Department did not have adequate documentation to demonstrate completion of this step prior to July 2025. An additional training, to be recorded, will be held with program staff Friday December 19th, 2025. Anticipated Completion Date: December 19,, 2025 Responsible Person(s): Autumn Watson, Business Operations Director
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency and Nonmaterial Noncompliance – Child Support Non-Cooperatio...
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency and Nonmaterial Noncompliance – Child Support Non-Cooperation Finding 2025-008 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The County should have adequate documentation for each participant that supports each sanction for noncooperation. Condition: a) There was one (1) instance out of two (2) sanctions tested where the required form to be sent was dated after the sanction start date. b) There was one (1) instance out of two (2) sanctions tested where the sanction was not properly documented. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: When required sanction notifications are not issued prior to the sanction start date and sanctions are not properly documented, there is an increased risk that clients may not be properly informed of program actions and that the County may not comply with program requirements. Cause: The County did not have adequate procedures in place to ensure that required sanction notifications were issued prior to the sanction start date and that all sanctions were properly documented in accordance with program requirements. Recommendation: The County should implement procedures to ensure all required sanction notifications are issued prior to the sanction start date and that sanctions are properly documented in accordance with program requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this, which is further discussed in the Corrective Action Plan. Corrective Action Plan: Performance Improvement Strategy: Collaborate with Child Support Services to improve understanding of their processes and ensure accurate case handling. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist), Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training and Development Manager), Scott Fritz (Social Services Manager), Program Supervisors Training: Non-Cooperation Sanction Training Anticipated Completion Date: To be completed quarterly. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist). Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training and Development) Anticipated Completion Date: Completed by January 2026.
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Material Weakness and Nonmaterial Noncompliance – Eligibility and Special Tests: In...
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Material Weakness and Nonmaterial Noncompliance – Eligibility and Special Tests: Income Eligibility and Verification System Finding 2025-007 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The County should have adequate documentation for each participant that supports each eligibility determination, and the information entered into NCFAST. We noted several errors related to the following compliance criteria: a) An OVS inquiry must be completed and agreed to information reported in NC FAST. b) For the month of application, Work First cash assistance payments are prorated from the date of application, with the date of application being day one. c) All Work First applicants must provide a Social Security number or apply for a Social Security number if they do not have one. d) Parents and step-parents who apply for children must be included in the case with the child, unless they are otherwise ineligible. Condition: The following are the results of nonmaterial noncompliance noted for each criteria listed above out of the 25 program participants selected for testing a) There were two instances where the OVS query was not run at the time of the determination. b) There was one instance where a hearing extension was incorrectly prorated. c) There was one instance where the social security number was not verified. d) There was one instance where kinship was not documented. Lastly, the following are the results of 60 program participants tested for control testing: a) There were three instances where the County did not remediate the errors identified within their internal review timely. b) There was one instance where a participant received benefits for one month where they should not have. c) There was one instance where incorrect forms were sent to a participant. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk the County could provide funding to individuals who are not eligible. Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis. Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified and monitored throughout the year for adherence to the policy. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: Performance Improvement Strategy: The Economic Services Division (ESD) Quality and Training Specialist will conduct a 25% sample review of all ongoing cases. Errors identified during these reviews will be documented and communicated to both the Social Services Supervisor and the assigned Eligibility Specialist for correction within a defined timeframe. Failure to comply with correction timelines will result in corrective action. Case Review and Error Notification • ESD Sr. Quality and Training Specialist will review 25% of all ongoing cases. • Errors will be documented on checking sheets and emailed to both the supervisor and the assigned Eligibility Specialist. • Corrections must be completed within 5 business days of notification. Corrective Action • If corrections are not completed within the extended timeframe: o Corrective Action will be initiated in accordance with departmental performance management protocols. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist), Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training & Development Manager), Scott Fritz (Social Services Manager), Program Supervisors Anticipated Completion Date: To be completed monthly. Training: Training Completion Required for the Following Quality Review Errors: • Ensure the OVS inquiry is completed, and that the information aligns with data reported in NC FAST. • Understand that Work First cash assistance payments are prorated from the application date, which is considered Day One. • Confirm that all Work First applicants must provide a valid Social Security number or apply for one if not already obtained. • Review and apply the rules of kinship, specifically regarding parents and stepparents. Additionally, train supervisors and eligibility specialists on the importance of timely resolution of quality sampling errors and how delays can impact audit outcomes. Responsible Individuals: Sr. Quality & Training Specialists, Quality & Training Supervisor, Training & Development Manager. Anticipated Completion Date: An email will be sent by the Staff Development Unit to the Eligibility Specialist with errors by January 2026, and in-person training will be completed by February 2026.
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