Corrective Action Plans

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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.
Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Significant Deficiency – Eligibility Finding 2025-005 Criteria: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective...
Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Significant Deficiency – Eligibility Finding 2025-005 Criteria: 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. Condition: There were 6 instances out of 60 program participants tested for control testing where the County did not remediate the errors identified within their internal review timely. Questioned Costs: None Effect: Failure to promptly remediate errors identified during internal review increases the risk that program participants may receive benefits or incur costs that do not comply with program requirements, potentially resulting in noncompliance and questioned costs. Cause: 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: 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: The WIC Sr. Quality and Training Specialist conducts quarterly monitoring by observing staff and completed random chart reviews. However, due to retrospective nature of audits significant time elapses between the occurrence of the error and its identification. Late corrections in the crossroads system will compromise data integrity and disrupt some of the certification processes in crossroads. Crossroads also lacks the ability to alert supervisors of missing documentation which in turn creates a huge administrative burden to monitor missing documentation in real time. WIC program leadership will create a policy that will address documentation standards. WIC staff will be instructed not to alter the original entry, instead a correction addendum will be documented to acknowledge missing data. WIC program will continue to provide policy refreshers every quarter to address these findings and provide staff updated information. WIC supervisors will review the quarterly audits results with their staff and ensure staff follow the standards set by the department leadership. The following the phases of the corrective action plan will be completed by March 31st, 2026. Phase 1: Review of Federal and State Guidelines Phase 2: Creation of Document Standard Policy Phase 3: Implementation of new documentation standards policy. Anticipated Completion Date: March 31st, 2026 Responsible Person(s): Ali Raza, WIC Director
U.S. Department of Agriculture Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Significant Deficiency – Procurement Finding 2025-004 Criteria: Pe...
U.S. Department of Agriculture Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Significant Deficiency – Procurement Finding 2025-004 Criteria: Per Section 200.318 of the Uniform Grant Guidance, a non-federal entity must use documented procurement procedures for the acquisition of services required under a federal or State award. Condition: The County did not properly follow the Uniform Grant Guidance procurement standards for contracted services tested. Specifically: a) There was one (1) contract out of two (2) contracts tested where the County did not retain proper documentation of the original bid process for a contract that was extended into the current year. b) There was one (1) instance out of two (2) contracts tested where the documentation of the rationale for utilizing a State contract was not properly documented. Questioned Costs: None. Effect: By not having the required documentation and rationalization in the files, the County could have improperly contracted with a vendor that was not considered eligible to be paid with grant proceeds. Cause: The County did not ensure all contracts utilized for the grant were properly documented using procurement requirements in accordance with the Uniform Grant Guidance procurement standards. Recommendation: The County should consider utilizing the Uniform Grant Guidance procurement standards for all County contracts to ensure proper documentation for contracts are maintained in the file. 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: The County’s procurement policy generally mirrors the Uniform Grant Guidance and procedures have been implemented to provide additional review of new agreements prior to execution to ensure that proper steps were followed in the selection process. In addition, the importance of comprehensive documentation retention in the areas noted above have been communicated to staff and a review of same will be included in the added review process. Anticipated Completion Date: December 31, 2025 Responsible Person: Teresa Rausch, Procurement Director
Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Significant Deficiency – Allowable Costs/Costs Principles Repeat Finding 2025-003 Criteria: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must esta...
Program Name: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number 10.557 Significant Deficiency – Allowable Costs/Costs Principles Repeat Finding 2025-003 Criteria: 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. Condition: There were 3 out of 40 samples tested where clear and consistent documentation of a control over allowable costs and activities was not present. Effect: Without consistent documentation and adherence to departmental policy for approving allowable costs, there is an increased risk that unallowable expenditures may be charged to the program, potentially resulting in noncompliance with federal requirements and questioned costs. Questioned Costs: None. Cause: The departmental policy to approve expenditure documents as an allowable cost for the program was not followed. Recommendation: The County should consistently follow departmental policy by ensuring all expenditure documents for the program are properly reviewed and approved as allowable costs before being approved for payment and maintain clear documentation of controls over program activities to support compliance with federal 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. Correction Action Plan: Program leadership will collaborate with the County Finance Team to ensure departmental policy is followed when purchases are made using WIC Federal funds. Internal purchase approval documents will be created to enhance the approval workflow. All purchases will be submitted to the WIC Program Director for approval. The program Director and the Sr. Admin Assistant will review the orders and ensure they are allowable items per the NC State WIC program guidelines. A shared folder will be created to save the purchase order forms, and the invoices to ensure Mecklenburg County Health Department Policy A-13, Retention of Administrative Documents is followed. The following the phases of the corrective action plan will be completed by March 1st, 2026. Phase 1: Review of Federal and State Guidelines Phase 2: Mecklenburg County Procurement Policy Review Phase 3: Creation and Implementation of new internal purchase approval processes. Phase 4: Staff Training Anticipated Completion Date: March 1st, 2026 Responsible Person(s): Ali Raza, WIC Director
Finding 2025-003 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 Finding Summary: In testing of 60 students, 1 student was identified that was notified of the requirement to retu...
Finding 2025-003 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 Finding Summary: In testing of 60 students, 1 student was identified that was notified of the requirement to return Title IV funds in excess of the amount actually required to be returned. The error was caught by the District, but the student’s account was never corrected to the appropriate amount of the return. Corrective Action Plan: The corrective action for the R2T4 calculation error involved promptly correcting the student's calculation and returning the appropriate funds. To prevent future mistakes, the Director of Financial Aid will review the current R2T4 controls process with staff, which now includes a double review by the Financial Aid Adviser and the Director to catch errors such as typos or miscalculations and to ensure accurate student notifications. After aid adjustments are made, the Director verifies the processed changes for accuracy, and any discovered errors are immediately corrected and documented in the R2T4 file. Responsible Individual(s): Christopher Natelborg Anticipated Completion Date: September 2025
Finding 2025-002 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 Finding Summary: In testing of 60 students, 1 student was identified who was not awarded the correct amount of Pe...
Finding 2025-002 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 Finding Summary: In testing of 60 students, 1 student was identified who was not awarded the correct amount of Pell. Corrective Action Plan: The corrective action for the Pell Grant eligibility issue involved promptly adjusting the affected student's Pell Grant to the correct amount, which resulted in an increase and ensured there was no negative impact. To address the root cause, the Director of Financial Aid met with the financial aid team to review the finding and clarified federal regulations on Pell Grant calculations, referencing the 2024-25 FSA Handbook. Importantly, the Director committed to upgrading the internal Pell Grant calculator used by Financial Aid Advisers: this enhancement will add a flagging mechanism that automatically alerts advisers whenever a student's calculated Pell Grant amount falls below the published minimum Pell amount for that award year, thereby ensuring that no student unintentionally receives an ineligible or reduced Pell Grant due to a calculation oversight. Responsible Individual(s): Christopher Natelborg Anticipated Completion Date: January 2026
Finding 2025-001 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 Finding Summary: In testing of 60 students, 3 students did not receive a timely notification of their award from ...
Finding 2025-001 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 Finding Summary: In testing of 60 students, 3 students did not receive a timely notification of their award from the District. Corrective Action Plan: To address missed disbursement notifications, the Financial Aid team identified affected students and sent the required notices, including an official explanation from the Director of Financial Aid. The issue was traced to a system malfunction during the SU24 term, which has since been resolved by implementing a process that alerts IT and the Director if notification counts do not match disbursement records. The notification script has been enhanced to track missing letters over the previous 30 days, and IT has established a weekly audit comparing sent notifications to disbursement records for accuracy. Additionally, coding updates in the CX system now ensure all disbursements are properly captured, regardless of the date entered by Financial Aid, thereby preventing similar oversights in the future. Responsible Individual(s): Christopher Natelborg Anticipated Completion Date: December 2025
Finding 2025-002 – Internal Control over Compliance – Reporting (Significant Deficiency) CFDA Title and Number 84.354A Qualified Zone Academy Bonds (QZAB) Name of Federal Agency: U.S. Department of Education Compliance/Internal Control over Compliance: Auditee Responsibilities - 87 - Criteria: Unifo...
Finding 2025-002 – Internal Control over Compliance – Reporting (Significant Deficiency) CFDA Title and Number 84.354A Qualified Zone Academy Bonds (QZAB) Name of Federal Agency: U.S. Department of Education Compliance/Internal Control over Compliance: Auditee Responsibilities - 87 - Criteria: Uniform Guidance CFR Part 200.303 requires entities to maintain effective internal control over compliance for federal programs, including accurate financial reporting. GAAP requires proper recognition and disclosure of long-term obligations such as Qualified Zone Academy Bonds (QZAB). In-ternal controls should ensure debt balances are reconciled to lender statements and amortization schedules to prevent misstatement in reports and the SEFA. Condition: Myrtle Point School District No. did not perform routine reconciliations of QZAB debt bal-ances during the fiscal year ended June 30, 2025. The general ledger balance for QZAB differed from the amortization schedule and accrued interest was not updated. No documented review or reconciliation was performed. Failed to report the interest for the QZAB bonds and failed to post the principal pay-ments that were paid from the QZAB for the Flex fund. Entries were required to correct this deficiency in order to complete the audit. Cause: Lack of formal reconciliation procedures and oversight; reliance on outdated schedules without updates. Effect or Potential Effect: Failure to accurately reconcile QZAB balances or amortization records, can result in a risk of material misstatement of liabilities and interest expense for the financial statements; po-tential errors in SEFA reporting when QZAB financed federally funded assets. This could lead to non-compliance with reporting requirements and misclassification of debt-financed assets. Questioned Cost: None reported Repeat of a Prior-Year Finding: Yes Recommendation: We recommend that Myrtle Point School District No. 41 implement a monthly recon-ciliation process for QZAB debt, agreeing general ledger balances to lender statements and amortization schedules, and require documented review and sign-off by the Director of Business Services. District's Response: The District concurs with the recommendation. Corrective Action Plan: The District will implement reconciliations and update the schedules, and inte-grate review into the year-end close process. Planned Implementation Date: January 31, 2026 Responsible Person: Director of Business Services, Myrtle Point School District No. 41
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