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The District concurs with the audit finding. The error occurred in the context of courses offered in modules, which are subject to unique federal calculation requirements. To address this finding and strengthen internal controls over R2T4 calculations for modular coursework, Lemoore College will imp...
The District concurs with the audit finding. The error occurred in the context of courses offered in modules, which are subject to unique federal calculation requirements. To address this finding and strengthen internal controls over R2T4 calculations for modular coursework, Lemoore College will implement the following corrective actions: 1. System-Based Calculation Tool Development Lemoore College will work with the District’s IT department to develop a tool that accurately calculates the percentage of the term completed for students enrolled in courses offered in modules. This tool will be designed to align with applicable federal R2T4 requirements and reduce reliance on manual calculations. 2. Interim Manual Calculation Controls Until the system-based solution is implemented, Lemoore College will implement enhanced review procedures for all R2T4 calculations involving modular coursework, including documented secondary review of the withdrawal date, module dates, and percentage of term completed. 3. Procedure Documentation and Staff Guidance Lemoore College will update internal procedures and provide targeted guidance to Financial Aid staff regarding R2T4 calculations for modular courses, including documentation standards and review expectations. 4. Ongoing Monitoring Supervisory monitoring and periodic spot checks will be conducted to ensure the continued accuracy of R2T4 calculations involving modular coursework.
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063 Recommendation: We recommend that the College review its procedures to ensure their internal system pulls the correct SAI amounts directly from the student's ISIR when calculating a student’s Pell award. Explanation of disa...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063 Recommendation: We recommend that the College review its procedures to ensure their internal system pulls the correct SAI amounts directly from the student's ISIR when calculating a student’s Pell award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure compliance, the College will implement the following corrective actions: 1. System Configuration Review: The Financial Aid Office, in coordination with Powerfaids (College Board), will conduct a comprehensive review of system configuration settings to confirm that SAI values are pulled directly and accurately from the student’s valid ISIR transaction when calculating Pell eligibility when PARM ROLL is run each year. 2. Validation and Testing: The College will perform test file reviews comparing ISIR SAI values to system-calculated Pell awards to confirm accuracy. Any discrepancies identified will be corrected through system reconfiguration or vendor-supported adjustments (as per College Board.) 3. Quality Control Review: A secondary-level review, (i.e., the counselors designated to their individual alphabet cohort) will be implemented during each awarding cycle to confirm that Pell awards align with the student’s valid SAI and enrollment intensity. These corrective actions strengthen internal controls over Pell awarding, ensure SAI data integrity, and mitigate the risk of future calculation discrepancies. Name(s) of the contact person(s) responsible for corrective action: Stephanie Schroeder, Director of Financial Aid Planned completion date for corrective action plan: Immediate action will take place, with the goal of implementing these changes effectively before the start of the new academic year
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are r...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are returned within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In the absence of the Bursar due to short-term disability, the Associate Bursar was not fully trained in processing credit balances within the required timeframe. Since then, under direction of the Bursar, the Associate Bursar has been trained and occasionally processes credit balances to ensure comfortability and accuracy. The College has evaluated and updated its policies and procedures regarding student credit balances to ensure that any credit balances as a result of Title IV aid are returned within the required timeframe. Name(s) of the contact person(s) responsible for corrective action: Julie Lanski, Director Student Financial Services/Bursar Planned completion date for corrective action plan: May 31, 2026
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend that the College review its reporting procedures to COD to ensure disbursements are reported timely and accurately to be in compliance with regulations. Explanati...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend that the College review its reporting procedures to COD to ensure disbursements are reported timely and accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure compliance, the College will implement the following corrective actions: 1. Established Reporting Timeline: All disbursements will be reported to COD within fifteen calendar days of the date of disbursement, in accordance with federal regulations. 2. Secondary-Level Review: We will make it a goal to have another person within the student finance office trained to perform bi-weekly or monthly reviews of COD transmission reports to confirm accuracy and completeness. Evidence of review will be documented and retained. These corrective actions strengthen internal controls, enhance monitoring processes, and ensure disbursements are reported to COD timely and accurately moving forward. Name(s) of the contact person(s) responsible for corrective action: Stephanie Schroeder, Director of Financial Aid Planned completion date for corrective action plan: Immediate action will take place, with the goal of implementing these changes effectively before the start of the new academic year
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College review its reporting procedures to ensure that key line Items within the Fiscal Operations Report and Application to Participate (FISAP) are reviewed ...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College review its reporting procedures to ensure that key line Items within the Fiscal Operations Report and Application to Participate (FISAP) are reviewed and accurately reported to Department of Education as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Controller will ensure that when reporting revenue on the FISAP that it properly breaks out Graduate tuition separately from all other Tuition. Name(s) of the contact person(s) responsible for corrective action: Lisa Ressman, Controller Planned completion date for corrective action plan: February 17, 2026
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reporting student's verification statuses to COD timely and accurately to be in compliance with regulations. Explanati...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reporting student's verification statuses to COD timely and accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure compliance, the College will implement the following corrective actions: 1. Policy Update: The Financial Aid Policies and Procedures will be revised to formally document procedures for reporting verification status updates to COD, including defined timelines and assigned responsibilities within the office. 2. Established Reporting Timeline: Verification status updates will be submitted to COD within ten business days of verification completion or any change impacting Pell eligibility. 3. Tracking and Oversight: A verification tracking log will be implemented to document completion dates and COD reporting dates within the Powerfaids system to ensure verification tasks are completed. 4. Staff Training: Financial aid staff will receive training in updated procedures and COD reporting requirements. These measures strengthen internal controls, enhance oversight, and ensure timely and accurate reporting of verification statuses to COD moving forward. Name(s) of the contact person(s) responsible for corrective action: Stephanie Schroeder, Director of Financial Aid Planned completion date for corrective action plan: Immediate action will take place, with the goal of implementing these changes effectively before the start of the new academic year.
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on determining student's withdrawals, specifically the proper calculation elements and proper rounding were necessary to ...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on determining student's withdrawals, specifically the proper calculation elements and proper rounding were necessary to ensure timely and accurate returns of Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Break days of 5 consecutive days or more were incorrectly added to PowerFaids during setup. The College has reviewed and updated its policies and procedures to show that both the Director of Financial Aid and the Bursar will review the number of days to be entered into PowerFaids to ensure that prior and post-weekend days are included in the scheduled break when applicable. 2) In manually calculating the Return of Title IV Funds, the adding machine was inadvertently not set to round to three decimal places as required. The Bursar is responsible for calculating Return of Title IV funds and will ensure that any manual calculations are rounded to three decimal places as required. Policies and procedures have been updated to reflect the requirements of this critical step. Name(s) of the contact person(s) responsible for corrective action: Julie Lanski, Director Student Financial Services/Bursar Planned completion date for corrective action plan: May 31, 2026
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reviewing enrollment status changes to NSLDS to ensure that all status changes are being reported timely and accuratel...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reviewing enrollment status changes to NSLDS to ensure that all status changes are being reported timely and accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar will review and strengthen the enrollment report to ensure it pulls all required information according to the needs of the National Student Clearinghouse (NSCL) and the NSLDS. The Registration and Records Office will continue to work with NSCL and NSLDS on specific enrollment scenarios that require different submission update requirements. Name(s) of the contact person(s) responsible for corrective action: Katelyn Letizia, Interim Vice President Institutional Effectiveness and Academic Strategy. Planned completion date for corrective action plan: May 31, 2026
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College evaluate its procedures and a policy around how Subsidized Stafford loans are calculated, awarded, and packaged. Explanation of disagreement with audit finding: There is no disagreement with...
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College evaluate its procedures and a policy around how Subsidized Stafford loans are calculated, awarded, and packaged. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The long-established process for prorating direct student loans for students entering their last term of study and scheduled to attend less than a full year relies on a loan proration chart kept by the financial aid office. This situation affects very few students each year. A minor error was made on one student’s award due to using an outdated proration chart. As soon as the error was discovered, the chart was updated and its accuracy will be confirmed annually.
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the College review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the College review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Additional IT resources have been employed to enable work to progress on the following WISP policies, targeting completion by May 31, 2026: - Change Management Policy - Periodic User Access Review Policy - Data Handling Policy - Patch Management Policy Name(s) of the contact person(s) responsible for corrective action: Mary Alma Noonan, Matthew Hoban Planned completion date for corrective action plan: May 31, 2026
Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster Federal Financial Assistance Listing #: 84.007, 84.033, 84.063, 84.268 Compliance Requirement: Special Tests and Provisions – Return of Title IV Funds Significant deficiency in internal control Findi...
Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster Federal Financial Assistance Listing #: 84.007, 84.033, 84.063, 84.268 Compliance Requirement: Special Tests and Provisions – Return of Title IV Funds Significant deficiency in internal control Finding Summary: One instance was identified where the amount of funds to be returned was not calculated/remitted correctly. Responsible Individuals: Randy Mashek, Financial Aid Director and Dawn Fleming, Assistant Director of Financial Aid Corrective Action Plan: The Financial Aid Office will collaborate with the full Student Services team (Advising, Registrar, Financial Aid, Finance) in order to continue a strong focus on the importance of the Return of Title IV Funds (R2T4) policy and procedures. This focus will improve the process in order to better accurately calculate R2T4s as well as communicate the importance of dates more effectively with students and staff regarding withdrawals and earned aid and the financial impacts of them. Implementation of certain measures has already begun in 2025-26 with the following steps: 1. Return of Title IV Funds (R2T4) calculations in real time as students withdraw from classes throughout the semester. Cross training for the administration staff processing withdrawals was implemented over the past two years. A checks and balances system are now in place to alert the Assistant Director and Director of Financial Aid whenever a complete withdrawal is made. Once the notification is made the Assistant Director reviews, calculates and processes the R2T4. The Director will perform a monthly quality sampling throughout the semester in order to review and test R2T4 calculations for accuracy and document when that happens. This process was in practice as the Assistant Director was being trained by the Director over the past year and now, we will begin to formalize that process as well as document each instance and build it into the workflow starting with the spring 2026 semester. 2. Additionally, ongoing training for R2T4 rules and regulations is completed throughout the year through our state and national associations (NASFAA and IASFAA) by the Assistant Director and Director as well as webinar and training from Federal Student Aid (FSA). From these trainings we will continue to share with Advising and support staff in order to educate and train them on the implications of withdrawals and the importance of earned aid dates, modular classes, class start and end dates, and college breaks that all impact the calculation of days in the R2T4 process and communication. Anticipated Completion Date: Ongoing. Fully functional with the start of 2026-27 year
Management acknowledges that certain internal controls did not operate effectively during the year ended June 30, 2025. Management is in the process of implementing additional controls to ensure a stable control environment that complies with procurement requirements.
Management acknowledges that certain internal controls did not operate effectively during the year ended June 30, 2025. Management is in the process of implementing additional controls to ensure a stable control environment that complies with procurement requirements.
This district has implemented a process where meal counts are reviewed and verified by the Business Office. Each month the business office receives a copy of the meal claim along with all backup with meal counts. The business office reviews the meal counts, verifies the totals and then verifies that...
This district has implemented a process where meal counts are reviewed and verified by the Business Office. Each month the business office receives a copy of the meal claim along with all backup with meal counts. The business office reviews the meal counts, verifies the totals and then verifies that the totals match the claim for reimbursement. Any discrepancies found are reported to the Cafeteria Manager for corrections to be made to the claim reimbursement.
Capitalization Grants for Clean Water State Revolving Funds SIGNIFICANT DEFICIENCY/NONCOMPLIANCE 2025 - 001 Cash Management Name of contact person: Heather Doughtie, Finance Director Corrective Action: Management will install measures to ensure future grant funds are expended with the required Cash ...
Capitalization Grants for Clean Water State Revolving Funds SIGNIFICANT DEFICIENCY/NONCOMPLIANCE 2025 - 001 Cash Management Name of contact person: Heather Doughtie, Finance Director Corrective Action: Management will install measures to ensure future grant funds are expended with the required Cash Management time limits. Proposed Completion Date: The Board will implement the above procedure immediately.
The City concurs with the finding. The City will update Continuum of Care procedures related to subrecipient monitoring, in-kind contribution documentation, match tracking and reporting, and grant closeout review to strengthen compliance and oversight. Additionally, the City will provide additional ...
The City concurs with the finding. The City will update Continuum of Care procedures related to subrecipient monitoring, in-kind contribution documentation, match tracking and reporting, and grant closeout review to strengthen compliance and oversight. Additionally, the City will provide additional grants training and a list of subject matter experts within each department that can work with auditors during the single audit.
The City concurs with the finding. The Department of Health, Housing & Homelessness will review the allocation of fringe benefits to grant payroll charges on a quarterly basis to ensure fringe benefits are properly allocated to funding sources. The reconciliations will be prepared by fiscal staff an...
The City concurs with the finding. The Department of Health, Housing & Homelessness will review the allocation of fringe benefits to grant payroll charges on a quarterly basis to ensure fringe benefits are properly allocated to funding sources. The reconciliations will be prepared by fiscal staff and approved by the Fiscal Manager. Additionally, the DFAS Grant Administrator will perform a semi-annual review of excess leave payouts to ensure they are charged to the correct grant funding string.
The City concurs with the finding. Beginning in December 2025, the Aviation Revenue and Finance Officer has implemented an internal control to strengthen compliance with federal reporting requirements. A centralized spreadsheet has been created to track all required financial report deadlines, inclu...
The City concurs with the finding. Beginning in December 2025, the Aviation Revenue and Finance Officer has implemented an internal control to strengthen compliance with federal reporting requirements. A centralized spreadsheet has been created to track all required financial report deadlines, including FAA Forms 5100-126 and 5100-127. This spreadsheet identifies the due dates, responsible personnel, and submission status to help ensure reports are prepared, reviewed, and submitted timely in accordance with applicable federal regulations. The Aviation Revenue and Finance Officer will also perform periodic reviews of the reporting calendar to monitor completeness, accuracy, and compliance to required deadlines.
Loras College Corrective Action Plan For the year ended June 30, 2025 February 19, 2026 Finding 2025-002: Significant Deficiency – Gramm-Leach Bliley Act Security Policy Assistance Listing Number: Various Federal Agency: U.S. Department of Education Condition: The College did not have updated proced...
Loras College Corrective Action Plan For the year ended June 30, 2025 February 19, 2026 Finding 2025-002: Significant Deficiency – Gramm-Leach Bliley Act Security Policy Assistance Listing Number: Various Federal Agency: U.S. Department of Education Condition: The College did not have updated procedures and processes in place specific to certain required GLBA elements. The GLBA policy review and updates are still in process. Recommendation: It is recommended that the College update its written GLBA Security Policy to address all the required elements. At a minimum, the College should address each of the required minimum elements noted in the GLBA regulations (16 CFR 314.4). Corrective Action: Management is reviewing its written GLBA policy to ensure all elements of 16 CFR 314.4 are included. The new written policy will be implemented no later than May 31, 2026. Renate A. Root Treasurer 1450 Alta Vista St. Dubuque, IA 52001 563-588-7775
Loras College Corrective Action Plan For the year ended June 30, 2025 February 19, 2026 Finding 2025-001: Significant Deficiency – Incentive Compensation Assistance Listing Number: Various Federal Agency: U.S. Department of Education Condition: One out of five employees selected for testing had a pr...
Loras College Corrective Action Plan For the year ended June 30, 2025 February 19, 2026 Finding 2025-001: Significant Deficiency – Incentive Compensation Assistance Listing Number: Various Federal Agency: U.S. Department of Education Condition: One out of five employees selected for testing had a promotion letter that included a salary increase if performance metrics for enrollments were met, with goal numbers for yearover- year increases in applications, admissions, new transfer enrollment and graduate enrollment. This is not in compliance with applicable requirements regarding incentive compensation. Recommendation: The College should establish a policy where employee contracts and compensation are reviewed and approved to ensure compliance with applicable requirements regarding incentive compensation per the regulations at 34 CFR 668.14(b)(22). Corrective Action: Management has reviewed internal processes and procedures and a process has been established whereby all employee contracts and compensation are first reviewed by the Associate VP for Finance/Treasurer and President before they are sent to Human Resources for processing. The Associate VP for Finance/Treasurer has a CPA background. In addition, the President and the HR Director are now well versed in applicable requirements regarding employee compensation. Management believes this process will eliminate a reoccurrence. Renate A. Root Treasurer 1450 Alta Vista St. Dubuque, IA 52001 563-588-7775
Finding 1175074 (2025-001)
Material Weakness 2025
None reported Finding 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Findings 2025-001 also apply to State requirements and State Awards. Margaret Pierce - Burke County Finance Director, Korey Fisher-Wellman - Department of Social Services Direct...
None reported Finding 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Findings 2025-001 also apply to State requirements and State Awards. Margaret Pierce - Burke County Finance Director, Korey Fisher-Wellman - Department of Social Services Director, Amanda Grady - Assistant Department of Social Services Director, and Tammy Wright - Medicaid Program Manager For all findings identified, Medicaid staff are required to attend training sessions to address the issues, and sign-in sheets will be required. During training, appropriate policies will be reviewed. The root causes of the errors were determined to be staff oversight and procedural lapses, compounded by policy changes, staff turnover, and the inexperience of some workers. Medicaid Supervisors will continue conducting 2nd Party Reviews. As cases are reviewed, supervisors will provide additional training as needed, either individually or in group settings. Training materials will be kept current and shared with the lead worker to ensure proper delivery. Workers will be required to complete refresher training when errors are found and collaborate with lead workers or supervisors for more detailed instruction or training. Group training will be scheduled if multiple workers demonstrate similar issues based on 2nd Party Review results. Supervisors conducting 2nd Party Reviews will examine two random cases per worker each month for timeliness and accuracy. In addition, two extra cases per worker will be spot-checked monthly to verify accurate resource entry. The Program Manager and Supervisors will monitor reports to ensure timeliness and require staff to document any cases that have gone overdue. These processes will help determine whether improvements have been made in resource accuracy. New employees will have notices and other correspondence reviewed before they are sent out to ensure accuracy. All new employees will continue to have 100% of their cases reviewed until supervisors determine they can process cases independently and correctly. Results from 2nd Party Reviews will be shared with the Program Manager, Assistant Director, and DSS Director. Corrections have been made to cases in error, and supporting documentation has been updated in NCFAST. Section IV - State Award Findings and Question Costs Supervisors will conduct training in response to the identified errors, with completion targeted by the end of January. Success will be measured through the results of ongoing 2nd Party Reviews. The agency will continue to monitor outcomes, provide group or individual training as needed, and address persistent issues through the disciplinary process when necessary. Additional training requirements and expanded, targeted spot-checks of cases will be implemented on an ongoing basis, based on continued findings, to further strengthen accuracy and compliance. Burke County, North Carolina Section III - Federal Award Findings and Question Costs Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings 139
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER – FEDERAL ALN 84.027 AND 84.173 2025-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding ...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER – FEDERAL ALN 84.027 AND 84.173 2025-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires Independent School District No. 16, (the District) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the special education cluster federal programs. During our audit, we noted the District did not have sufficient controls in place within its special education cluster federal programs to ensure compliance with federal requirements related to assuring that the District was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review its policies and procedures relating to suspension and debarment for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to assure that district personnel are following the requirements of the Uniform Guidance related to suspension and debarment, including maintaining appropriate documentation. Official Responsible – The District’s Executive Director of Business Services, Amy Schultz Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Executive Director of Business Services, Amy Schultz will assure appropriate internal controls and procedures are in place to ensure compliance with suspension and debarment requirements.
2025-002 Inadequate Documentation of Timesheet Approval for Payroll Costs Charged to the Grant - Significant deficiency in Internal Control over Compliance Name of Contact Person: Daphne Chan, Interim Head of Finance Corrective Action: Lifelong Medical Care will: - Continue to update configuration o...
2025-002 Inadequate Documentation of Timesheet Approval for Payroll Costs Charged to the Grant - Significant deficiency in Internal Control over Compliance Name of Contact Person: Daphne Chan, Interim Head of Finance Corrective Action: Lifelong Medical Care will: - Continue to update configuration of the newly implemented payroll system to adequately support processes - Revise the payroll and timekeeping policy to clearly require electronic or manual supervisory approval for all hourly timesheets before payroll processing. - Provide refresher training to supervisors on federal grant requirements related to allowable payroll costs and the necessity of timely timesheet approval. - Implement a periodic monitoring process to review samples of timesheets each pay period to confirm that approvals are documented and retained. - Maintain approved timesheets in accordance with the Lifelong's document retention policy and federal grant requirements. Estimated Completion Date: June 30, 2026 Signed by Daphne Chan Interim Head of Finance
2025-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Daphne Chan, Interim Head of Finance Corrective Action: Management implemented staff training and periodic internal reviews in response to the prior year finding related to the ...
2025-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Daphne Chan, Interim Head of Finance Corrective Action: Management implemented staff training and periodic internal reviews in response to the prior year finding related to the Sliding Fee Discount Program. While these actions improved awareness of requirements, management identified the need for additional controls to ensure consistent application and documentation going forward. To address the remaining gaps, management will implement the following actions: - Strengthen intake and documentation controls by reinforcing procedures to ensure proof of income documentation is obtained and retained. - Train site staff to ensure consistency in applying sliding fee discount. - Routine spot checks with timely escalation to Site Directors and Operations leadership when issues or variances are identified. - Refine internal monitoring activities to focus on higher risk transactions, such as new patient registrations, income re-certifications, etc. for final eligibility determination. Management will continue to monitor the effectiveness of these controls and make adjustments as needed to ensure ongoing compliance with Health Center Program requirements. Estimated Completion Date: June 30, 2026 Signed by Daphne Chan Interim Head of Finance
2025-002 Reporting Federal Assistance Listing Number: 10.553, 10.555 Program Title: Child Nutrition Cluster Federal Agency: U.S. Department of Agriculture Passthrough Entity: Arizona Department of Education Passthrough Number: ADE ED09-0001 Compliance Requirement: L. Reporting Award Period: July 1, ...
2025-002 Reporting Federal Assistance Listing Number: 10.553, 10.555 Program Title: Child Nutrition Cluster Federal Agency: U.S. Department of Agriculture Passthrough Entity: Arizona Department of Education Passthrough Number: ADE ED09-0001 Compliance Requirement: L. Reporting Award Period: July 1, 2024 – June 30, 2025 Finding Type: Noncompliance, Significant Deficiency in Internal Control Questioned Costs: N/A Repeat Finding: No. Condition/Context: During our review of meals claims submitted for reimbursement, we noted variances between the District’s meal counts and what was submitted to the Arizona Department of Education. For four months tested, meals claims were under-reported by 20 lunch meals, which calculated to $90.80. Criteria: Child Nutrition Cluster claim forms should be supported by documentation showing the number of meals for which reimbursement was requested. This documentation should be maintained to support what was requested for reimbursement by ADE. Effect: Without proper controls over applications and the filing of claims, the District could over or under claim their reimbursements from the Child Nutrition Program without detecting the error. Corrective Action Plan: Management will ensure meals claims are reviewed, approved, and tie to supporting meals served before claims are submitted. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Elizabeth Ibarra, Business Manager
Condition: During review of 40 eligibility determinations and redeterminations, we identified two exceptions: one case lacked documentation of IEVS reports required to verify income and eligibility information, and another case had a redetermination completed more than 12 months prior to the active ...
Condition: During review of 40 eligibility determinations and redeterminations, we identified two exceptions: one case lacked documentation of IEVS reports required to verify income and eligibility information, and another case had a redetermination completed more than 12 months prior to the active eligibility date, which does not comply with the annual redetermination requirement under 42 CFR 435.916. Recommendation: CLA recommends that the County strengthen monitoring procedures to ensure that Income and Eligibility Verification System (IEVS) reports are obtained and retained for all eligibility determinations, implement controls to verify that redeterminations are completed within the required 12-month timeframe prior to the active eligibility date, and provide staff training on compliance requirements and proper documentation standards to reinforce adherence to established policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: All eligibility units will review the updated CP 25- 01 “EFAS IEVS Process” by 2/27/26 and annually thereafter. Supervisors will monitor CalSAWS reports/tasks for assigned staff to ensure compliance with processing standards. Supervisors will also monitor CalSAWS Monthly Productivity reports for their units to ensure that Redeterminations are completed timely and include Medi-Cal redeterminations in the case review process for new and journey-level staff. Eligibility Specialists will review the memo MC 25-016 “Updated Medi-Cal Annual and Change in Circumstance RE Guidance” by 2/27/2026. To avoid late redeterminations, staff will be offered overtime opportunities to ensure compliance until such time as the units have enough staff to meet the workload. The Department will complete minimally two eligibility induction training classes and two journey level refresher trainings per year. Name(s) of the contact person(s) responsible for corrective action: Rachel Ebel-Elliott, Social Services Deputy Director Planned completion date for corrective action plan: 6/30/2026
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