Corrective Action Plans

Management Response: The College concurs with the finding and is in the process of implementing a policy when satisfactory academic progress is run, students will be notified via mail or email of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.

Management Response: The College acknowledges and concurs with the finding. The College is in the process of implementing changes to the student information systems and related process to accommodate both the internal enrollment polices and required reporting statuses, and enhances monitoring processes to ensure the integrity and punctuality of data reported to the NSLDS.

CORRECTIVE ACTION PLAN A. Comments on Findings and Recommendations: We agree with the finding and recommendation. B. Actions Taken or Planned: Upon review, the institution has found this to be an isolated incident due to human error. Additional refresher training has been performed to reinforce understanding of processes.

Finding 2024-002 – Student Financial Aid Cluster, Assistance Listing # 84.063 and 84.268 Limestone University utilizes Jenzabar software to extract and report enrollment data to the National Student Clearinghouse (NSC). However, in some instances, the data reported was incorrect. Since the occurrence of this issue, the University hired a new Registrar in August 2024. After reviewing the findings, the Registrar implemented the use of the NSC Edit Student Data Records window, in addition to the NSC Edit Registration Transactions window. This change allows a special status on the NSC Edit Student Data Records window to override the status on the Registration Transactions window, providing more precise monitoring of withdrawal dates and ensuring the accuracy and timeliness of the data reported to NSC. To ensure ongoing accuracy, the Registrar now reports enrollment status changes to NSC on a monthly basis. Additionally, the University reviewed the students identified in the findings, along with other students who had the same status (withdrawn) and made adjustments as necessary to ensure that all student data was accurately reported.

Finding 2024-002 – The Organization’s current documented procurement policy does not contain all the required elements identified within the Uniform Guidance. 2024-002 Recommendation: The Organization should adopt a formal procurement policy that complies with 2 CFR 200, Sections 200.318 through 200.327. Action Taken: Management agrees with the finding and will review the requirements under the Uniform Guidance relating to procurement and establish a formal policy and related procedures to comply with those requirements. Expected Date of Completion: June 30, 2025

Finding 2024-001 – Salaries and wages of employees charged or allocated to the major program were not supported by formal records that accurately reflect the work performed. During our testing of four payroll transactions, we noted three timesheets had no approval and the Organization recorded amounts based on budgeted estimates rather than actual amounts for all four payroll transaction tested. For those payroll transactions tested, two transactions were overcharged by $563 and two were undercharged by $527 resulting in a net overcharge to the grant of $36. The sample was not intended to be, and was not, a statistically valid sample. 2024-001 Recommendation: We recommend the Organization implement a process and related controls related to review and approval of payroll expenditures for allowability in accordance with the terms of the grant award and federal regulations. Payroll amounts charged to the grant should be based on actual time and effort reported by the employee working on the grant and related documentation maintained by the Organization to support those amounts. The Organization should implement a review process over recording time and effort for payroll transactions, for proper classification and allowability. Action Taken: Management agrees with the finding and has taken corrective action by formally adopting controls which will track the employee’s actual time spent. These controls were placed in service during the year ended June 30, 2024, but were not in place for the entire year. Date of Completion: February 16, 2024

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-002: Reporting: Pell Grant Disbursement Data Condition Found: In the auditors’ testing over reporting of Pell Grant disbursement data for the year, they identified a total of twenty-three late submissions of the forty samples reviewed. Recommendation: The auditors recommend the University enhance our internal control over compliance with the federal regulations related to reporting of Pell Grant disbursement data. The University should maintain an appropriate level of staffing to properly perform timely reporting of Pell Grant disbursement information to the COD system. The University should also align the internal control process of reporting Pell Grant disbursement data regardless of semester to eliminate manual errors. University of Delaware Corrective Action Plan: The University agrees with the finding. These late reporting stemmed from two issues. The fall and spring delays were related to errors in the reporting file, which caused the disbursements to fail in processing through the COD via the electronic batch process. The Student Financial Services team identified these errors during their reconciliation process, generally completed weekly. However, during part of the last academic year, this schedule was not consistently followed due to staffing issues. In addition to the fall and spring delays, there were delays in reporting summer Pell disbursements. This delay was directly related to correcting the University’s self-identified issue with the awarding and disbursement of funds during the Winter term related to Finding 2024-001. The University has corrected the processing of Pell during the winter term which will eliminate the sequencing issue. Additionally, the University has implemented electronic batch processing to COD for the summer term and addressed staffing issues to ensure that the reconciliation process continues on a weekly basis. Completion Date: November 1, 2024 Contact Person: Amanda Steele-Middleton, Assistant Vice President for Enrollment Management

Corrective Action Plan Year Ended June 30, 2024 Finding 2024-001: Disbursements: Pell Grant Condition Found: The University utilizes a standard term calendar and therefore should calculate federal student aid under Formula 1 (Volume 7, Chapter 1). Under Formula 1, institutions generally calculate a student’s Scheduled Award and splits such award evenly between the fall and spring semesters. The University offers a winter intersession, but did not combine the winter intersession with the fall or spring semester as prescribed by the Federal Student Aid Handbook when calculating federal student aid awards under Formula 1. Instead, the University used Formula 3 to calculate Pell Grant awards and treated the winter intersession as a separate term and awarded Pell Grants to students for the Winter 2024 intersession. In 2024, the University identified that such approach did not align with applicable Title IV regulations and Department guidance. By using Formula 3 to calculate Pell Grant awards, the University exceeded the students’ standard Scheduled Award. The total amount of over-awarded Pell Grants for the 2023-2024 academic period was $698,000. Recommendation: The auditors recommend the University enhance our internal control over compliance with the federal regulations related to disbursement of Pell Grant awards. The University should enhance how we receive, and process external information to ensure the University is properly awarding federal student aid in accordance with Title IV regulations and Department guidance. Additionally, a control should be designed and implemented for the review of such information. University of Delaware Corrective Action Plan: The University agrees with the finding. The University identified this issue as a result of an extensive review of processes, procedures and internal controls within Student Financial Services with the assistance of both external consultants and outside counsel. Through the University’s research, it was determined that this issue began in 2018 with the reintroduction of Year-Round Pell. The over-awarded amount resulted from the misinterpretation of the regulations and associated guidance and use of the incorrect formula. The University self-identified the issue with the Department of Education and is working towards resolution. The questioned costs of $698,000 related to fiscal year 2024 were refunded to the government through COD system as of September 30, 2024. The University is working with the Department of Education to open prior periods to finalize the repayment of an additional $1.9 million which is expected to be completed by June 30, 2025. The University has implemented internal controls which include the use of the Peoplesoft delivered tools to ensure that Pell is awarded using Formula 1 in accordance with Title IV regulations and Department guidance. The information related to winter intersession aid has been updated to specifically address winter Pell and ensure that it meets required regulations for attaching an intersession to a standard term when using Formula 1 for calculating Pell grant eligibility. Additionally, the University has implemented a weekly reconciliation and over-award reports to monitor for compliance. Completion Date: Return of $698,000 Questioned Costs: September 30, 2024 Implementation of Weekly Reconciliations: November 1, 2024 Return of Additional $1,900,000: Anticipated June 30, 2025 Contact Person: Amanda Steele-Middleton, Assistant Vice President for Enrollment Management

Condition During our testing, the College was unable to provide evidence of these Direct Loan reconciliations being performed monthly. Corrective Action(s): Community Christian College will include cash management for Direct Loans into our reconciliation process: Monthly meetings will be held each month between the Financial Aid Department and the Accounting Department. Monthly reconciliation will begin May 2025.

Condition During our testing over the NSLDS reporting requirements, the following deficiencies were noted: 3 of 50 program reporting details did not agree with enrollment details from the enrollment records per the College. 24 of 40 students did not have campus reporting completed within the required timeframe. Corrective Action(s): Community Christian College has established the following procedure to ensure timely reporting to NSLDS on behalf of our students. The implementation of bi-weekly Change in Status meetings to identify enrollment updates on the campus level will assist us in updating student statuses in CCC’s student information system. Community Christian College will implement a bi-weekly reconciliation process where discrepancies will be flagged, investigated, and corrected during that time. CCC will do a mass reconciliation immediately and begin the bi-weekly reconciliation process in June 2025. Additional measures: The Director of Financial Aid will conduct mandatory NSLDS reporting training for all relevant staff, including how to identify and correct discrepancies and if seen fit, assign a designated enrollment reporting coordinator to work closely with our 3rd party servicer to ensure accurate and timely reporting.

Condition During our testing over the return of credit balances, the following deficiencies were noted: 􀁸 8 instances where credit balances were not refunded in the required time frame. 􀁸 11 instances where refunds were due to students, but none were posted in the ledger. 􀁸 7 instances where the balances refunded to students could not be recalculated. Corrective Action(s): Community Christian College has established the following procedure to ensure the timely return of credit balances: The college will revise and formalize the institutions credit balance refund policy to align with federal regulations. The college will implement a centralized tracking log to include fields for credit balance creation date, refund due date, refund issue date, and reconciliation status. The reconciliation process for unresolved credit balances/refunds will begin April 21, 2025 and should be completed by April 25, 2025. CCC will begin developing a tracking process to have in place for next start in June 2025. Additional measures: Community Christian College has established a bi-weekly reconciliation process to take place between the Accounting Department and the Financial Aid Department; this internal audit will ensure the credit balances aligns with federal regulations. Furthermore, the Director of Financial aid will conduct trainings will all parties of both departments.

Condition The College did not retain supporting evidence utilized for reporting certain critical information within the FISAP including: 􀁸 Total number of students 􀁸 Total tuition and fees 􀁸 Information on eligible applicants Corrective Action(s): Community Christian College will establish a pre-submission review process where the Director of Financial aid will verify that all data reported in the FISAP is accompanied by appropriate supporting evidence: The college will use reports made available by our 3rd Party Servicer to report accurate data each FISAP submission year. This process will begin for the 26-27 Award year.

Condition During our procedures over Return to Title IV requirements, the following deficiencies were noted: 􀁸 7 of 13 Return to Title IV calculations were performed outside of the allowable time frame. 􀁸 1 of 13 withdrawn students did not have a Return to Title IV calculation performed. 􀁸 2 of 6 instances where funds were returned beyond the required time frame. Corrective Action(s): Community Christian College has established the following procedure to ensure timely and compliant processing of Return to Title IV (R2T4) calculations: The College will conduct bi-weekly Change in Status meetings to proactively monitor and identify any enrollment changes within the active student population. This process enables the timely identification of students who have recently withdrawn or are pending withdrawal. By doing so, the institution is able to initiate the R2T4 process promptly and ensure its completion within the federally mandated 30-day timeframe, thereby maintaining compliance and upholding institutional accountability. The bi-weekly Change in Status meetings will begin May 2025 and will continue as such, with adjustments made as needed. Additional measures: Community Christian College’s Registrar will notify respective parties of any enrollment changes; this ensures no changes go unnoticed between biweekly meetings.

Identifying Number: 2024-005 Finding: Disbursements to or on Behalf of Students (Credit Balances) The College did not pay the Title IV credit balance to the student directly for one student within the required timeline noted above. Out of the 40 students tested, we noted one student (2.5%) who’s credit balance was not paid directly to the student within the required timeframe noted above. The incorrect timing did not have an effect on the total award given to students (timing only). The College did not have formally documented controls related to the process associated with disbursements to or on behalf of students (credit balances), which is required under Uniform Grant Guidance. Corrective Actions Taken or Planned: The College has consistently worked to streamline the refund process in Student Financial Services and coordination with the Business Office. This process will be further enhanced by process improvements with the transition from CX to J1 in July 2025. Person Responsible: Leigh Brinson, lbrinson@knox.edu Anticipated completion date: July 2025

Identifying Number: 2024-004 Finding: Common Origination and Disbursement Reporting The College incorrectly reported the COA to COD for 3 students. Out of the 34 students tested, we noted 3 students (8.8%) whose COA was incorrectly reported to COD. The incorrect reporting did not have an effect on the total award given to students (reporting only). The College did not have formally documented controls related to the processes of enrollment reporting and reporting, which is required under Uniform Grant Guidance. Corrective Actions Taken or Planned: The College has moved Financial Aid packaging for all students from CX to PowerFAIDS. This transition has removed the manual processes that caused this error. Person Responsible: Leigh Brinson, lbrinson@knox.edu Anticipated completion date: September 2024

Identifying Number: 2024-003 Finding: Error in Reporting for National Student Loan Data System (NSLDS) The College did not properly report the student enrollment change for students who received federal student aid to the NSLDS. The College did not timely report three students’ Program-Level or Campus-Level enrollment status change to NSLDS. Out of the 11 students tested, we noted 3 students (28%) whose status change at the Program-Level and Campus-Level was not timely reported to NSLDS. The College did not have formally documented controls related to the process of enrollment reporting, which is required under Uniform Grant Guidance. Corrective Actions Taken or Planned: The Registrar’s office is implementing new processes to provide timely filing of clearing house data. This process will be further improved with the transition from CX to J1 in summer 2025. Person Responsible: Patrick Hathaway, phathaway@knox.edu Anticipated completion date: March 2025

Identifying Number: 2024-006 Finding: Graham Leach Bliley Act – Student Information Security The College’s written information security program did not include the following elements required by regulation as agreed to in the PPA.  The College has performed a risk assessment utilizing internal resources but has not based the information security program on the results of this assessment, nor has the College included all required elements of internal and external risks to the security, confidentiality or integrity of customer information. The College’s risk assessment is missing an inventory of IT systems that process and store customer information and the compliance with information security elements related to multifactor authentication, access control, change management, logging and alerting and encryption.  The College has not identified, designed or implemented safeguards for all of the risks identified in the risk assessment. The safeguards do not include the identification of security events or detection and response capabilities to support incident response.  The College has not been able to test safeguards because safeguards have not been designed or implemented in response to the risk assessment.  The College has not developed written policies and procedures to ensure that personnel are able to enact the information security program. There is a lack of evidence of leadership being required to report to the board or an appropriate supervisory council to ensure those charged with governance are informed on the current state of the information security program. The College has not developed policies and procedures to oversee information service providers Corrective Actions Taken or Planned: For the past 2 years, the College has been systematically addressing its IT and IT Security needs. These practices were updated in January 2023 and the policies have been formalized in November 2024. Person Responsible: James Stevens, jstevens@knox.edu Anticipated completion date: November 2024

Finding Number 2024-003– Enrollment Reporting Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has strengthened the review process by reinforcing the dual- review control system. In this system:  Control #1 (Financial Aid Coordinator) is responsible for conducting the initial review of the NSLDS Enrollment Report roster, performing data entry, and updating the status.  Control #2 (Financial Aid Manager) performs a secondary review and signs off on all NSLDS roster files before submission. Additionally, a log of all NSLDS submissions will be maintained, with both reviewers' signatures, to ensure proper documentation and accountability. Action Plan: The anticipated completion date for Finding Number 2024-0003 is March 2025

Finding 2024-002 – Special Tests and Provisions – Return of Title IV Funds Contact Person(s): Shanell Tilo, Financial Aid Officer Dr. Emilia Le’i, Dean of Student Services Dr. Letupu Moananu, Vice President of Academics, Community, and Student Affairs Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective actions taken/planned: The Financial Aid Office has updated the Financial Aid Handbook, Standard Operating Procedures (SOP), and the R2T4 total days calculation chart to exclude scheduled breaks of five or more consecutive days. To ensure compliance with these updates, the Financial Aid Office conducted a policy review session with the financial aid staff. Additionally, mandatory training sessions were held to reinforce R2T4 calculation procedures, with a specific focus on the proper exclusion of scheduled breaks. The Financial Aid Manager is responsible for calculating the total days for R2T4 purposes each award year. The Financial Aid Officer performs a secondary review to verify the accuracy of these calculations. Action Plan: The anticipated completion date for Finding Number 2024-0002 is March 2025.

The College will continue to adjust procedures as determined necessary to ensure that students are properly identified to provide them with exit counseling materials.

The College will make the necessary correction to the student's award. Review procedures will be conducted for student awards and disbursements to ensure accuracy for the next fiscal year.

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system (Banner from Ellucian). All students who have withdrawn are being updated through National Student Clearinghouse and from there to NSLDS.

Update internal financial aid disbursement policies to require annual and mid-year reviews of Pell Grant schedules. Implement a compliance checklist for verifying disbursement amounts.

Management concurs with the finding. The specific occurrences will be reviewed to determine the cause. In addition, the procedure to facilitate drawdowns after funds have been disbursed will be reemphasized to ensure compliance with the three-business day disbursement rule from the time of drawdown. The Student Financial Aid Office (SFA) will authorize Title IV awards and notify the Bursar and the Grants Account. The Bursar will facilitate disbursement of the funds to the students’ accounts and notify the Grants Accountant once the disbursement has been processed. The Grants accountant will facilitate the drawdown of funds after the funds have been disbursed. This will mitigate the potential recurrence of funds being drawn down prior to being disbursed to students’ accounts resulting in the potential for noncompliance with the three-day window.

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure Foster Care Maintenance payment rates were properly calculated. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action in progress Corrective Action: The Department concurs that policies and procedures related to rate setting for Foster Care maintenance payments are not currently established and is committed to strengthening internal controls and complying with federal requirements. In February 2025, the Department met with the State Auditor’s Office to gather an understanding of concerns and discuss how reasonable and allowable rates could be documented to ensure federal compliance. The Department will prioritize establishing written policies and procedures for setting payment rates to ensure maintenance payment rates only include allowable costs. Completion Date: Estimated July 2026 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov