Corrective Action Plans

Condition: During our review of the return of Title IV funds, we noted that students were not being properly identified as withdrawn, either officially or unofficially. This resulted in 7 students noted that never had a calculation performed, but should have, and 22 students that were reported late. Criteria: When a recipient of Title IV funds withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must perform a Return of Title IV Funds calculation to determine the amount of Title IV assistance the student earned as of the student’s withdrawal date. Cause: Student Financial Aid personnel does not have a method to properly identify students who are required to have a return of funds calculation. After several attempts to obtain a listing of students, the auditors requested assistance from the IT department, who was able to get the auditors a list very quickly. This list was compared to Student Financial Aid recipients to identify the population of students who should have had a calculation performed. Effect: Funds required to be sent back to the Department of Education are either missed or are late. Perspective: There has been high turnover in the SFA department, including a time where there was not a Director in place. Recommendation: We recommend training of Student Financial Aid personnel on the rules and regulations over return of funds. In addition, we recommend that Student Financial Aid personnel work with the IT department to develop a report that can be ran weekly or bi-weekly to identify the students and timely prepare the calculations. Views of Responsible Officials and Planned Corrective Actions: Dodge City Community College staff involved are undergoing training to learn requirements. Processes and procedures are being developed to ensure timely calculations and refunds.

Condition: There were no monthly Title IV reconciliations performed. Criteria: Per SFA requirements, the College is required to reconcile the COD data files with the College’s financial records. Cause: Turnover in the staff and Director positions of the College. The new employees were not aware of this requirement. Effect: Noncompliance with SFA requirements. Perspective: There has been high turnover in the SFA department, including a time where there was not a Director in place. Recommendation: We recommend that the direct loans are reconciled at least monthly between the COD and the College’s general ledger. Views of Responsible Officials and Planned Corrective Actions: Dodge City Community College staff involved have received training and been made aware of requirements. Monthly reconciliations will be performed immediately.

Condition: We examined a sample of Title IV aid recipients to verify that information reported on the Enrollment Reporting roster file sent to the National Student Loan Data System (NSLDS) matched the student's academic files and found instances where students received Title IV aid during a semester but the status of withdrawn or graduate were not reported correctly or timely on the NSLDS Enrollment Reporting roster files sent during that semester. Criteria: Per the NSLDS Enrollment Reporting Guide, a school should report all students that NSLDS includes in its request to the school on a roster file. This includes timely and accurate reporting of the status of the student of withdrawn or graduate. Cause: The status of the students were not timely and accurately reported to NSLDS. Effect: Students could potentially not be placed in grace or repayment status when they should be. Perspective: There has been high turnover in the SFA department, including a time where there was not a Director in place. They have had interim Director who also left in December 2023. A new Director has been hired in January 2024 and has begun working on issues. Recommendation: We recommend that personnel in charge of enrollment reporting be diligent in reviewing the roster file to ensure that all appropriate students are shown and attendance changes are reported in a timely and accurate manner. Views of Responsible Officials and Planned Corrective Actions: Dodge City Community College staff involved in enrollment reporting to the NSLDS have reviewed the NSLDS Reporting Manual to better understand and accurately report the student's enrollment status. There has been high turnover in the SFA department, including a time where there was not a Director in place. The new Director came on in the fall of 2022 and then left in December 2023. The College is still working on fully implementing new procedures and catching up submissions.

Finding No. 2023-002 Corrective Action Plan: The University concurs with the finding. The Financial Aid office is in the process of tightening its policies and procedures to identify all students subject to the required exit counseling, with the goal of delivering said counseling within the prescribed 30-day window. Responsible Official: John Sircy, Interim CFO Anticipated Completion Date: June 2024

Individuals Responsible for Corrective Action Plan Wanda Spradley, Director, Financial Aid Susan Kennon, Registrar Jennifer Sauer, AVP for Finance Corrective Action Plan: The finding is related to required enrollment information being reported to National Student Loan Data System by the registrar’s office. The errors noted in 2023-001, as well as 2022-001, were primarily related to a lack of internal systems, staff, and expertise in the reporting requirements. A new registrar was hired September 2023, and much work has been done to increase staffing and technology support for the office. The administration is working with the registrar’s office to implement controls to reduce errors and improve timeliness. However, reporting requirements are rigorous, and there will always be challenges. With new systems only recently put in place and the staffing issues continuing in FY23-24, this finding may be noted again next year. Anticipated Completion Date: June 30, 2024

Recommendation: We recommend that the University implement a procedure to ensure that all necessary MPNs are retained in accordance with the federal regulation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the audit finding where some MPNs are missing. We are unable to correct the past but moving forward, the new ones are being retained. Name of the contact person responsible for corrective action: Michelle Hegarty, CFO Planned completion date for corrective action plan: September 1, 2023

Recommendation: We recommend that the University review its procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agree with the audit finding and will implement procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Name of the contact person responsible for corrective action: Michelle Hegarty, CFO Planned completion date for corrective action plan: Already in place

Recommendation: We recommend reviewing the components of the enrollment roster file to ensure the correct effective date is reported correctly for both the "Campus Level" and "Program Level". Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the audit finding and will pull a sample of records each week after each NSC submission to ensure information has been passed onto NSLDS. Name of the contact person responsible for corrective action: Kris Ragozzino, Registrar Planned completion date for corrective action plan: Already in place.

Enrollment certifications will be sent to the National Student Clearninghouse on a monthly basis, no later than 10 days following the end of the month. The final degree file will be submitted no later than 30 days after the last day of class, with additional awards submitted individually. The Financial Aid Director will review all NSLDS errors.

Doane has reviewed the finding and is researching ways to improve the process.

The Financial Aid team is conducting staff training regarding return to Title IV calculations and compliance led by the Financial Aid Director. This includes all return to Title IV calculations being reviewed by the Financial Aid Director before final submission.

Management is responsible for establishing a comprehensive information security policy to safeguard sensitive data. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Management will continue to implement the remaining compliance requirements into a comprehensive policy.

Federal Direct Loan and Pell disbursement dates per the University's billing system did not agree with the reported dates per the Common Origination Disbursement (COD) records. Additionally, Pell award amount did not agree between the students' file and COD records. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Pell and Direct Loan origination records and disbursement records are submitted to the Common Origination Disbursement (COD) either same business day, or next business day. Formal reconciliation process is now completed every month in order to verify disbursement dates and amounts in COD.

Enrollment information was not submitted accurately or within the required timeframe by the University. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Management has hired a new Student Financial Services Director and is aware of the federal regulations surrounding enrollment information that must be reported to the NSLDS. Given the complexity of the reporting, management has established additional policies and procedures to address the errors related to enrollment reporting to the NSLDS in a timely and accurate manner.

Pacific understands finding #2023-002 and we agree that the University will enhance its internal controls to ensure all Pell disbursements are reported to COD within 15 days from the initial disbursement. Finding #2023-001 Action: The University notes that in the fall of 2022, there were students whose Pell Grant disbursements were not reported within the 15-day requirement to the Common Origination and Disbursement (COD)system. A Banner system issue allowed the origination of the Pell Grant to be sent to COD, however the disbursements were not. There was no indication this was occurring. To prevent future instances of late Pell Grant reporting, we will take the following action, effective February 6, 2024: • Adding an internal reconciliation component to the 10 day Pell Grant processing reminder • Reconciliation will be completed by the Assistant Director of Financial Aid, Operations of Analytics • Reconciliation will be reviewed and approved by Senior Assistant Director of Financial Aid, Operations and Analytics or Director of Financial Aid, Operations and Analytics Person(s) responsible: Aquila Galgon | Assistant Vice President of Financial Aid and Enrollment Strategy

Finding Number: 2023-006 Condition: Of the 9 students selected for enrollment reporting testing, the Seminary did not properly update student enrollment Information for 1 student in a timely manner. Planned Corrective Action: For students who finish their degree in December, they are reported as "withdrawn" as there is no option to confer in December (institutional policy). The student status is updated to "graduated" and reported to Clearinghouse in May when students are conferred. Contact person responsible for corrective action: Vince McGlothin-Eller, Registrar Anticipated Completion Date: 05/31/2024

Finding Number: 2023-005 Condition: During our review of internal controls and testing procedures, it was noted that no reconciliations could be provided. In addition, the Seminary does not have a quality assurance system in place. Planned Corrective Action: Within 1-2 weeks of each month's end, the Financial Aid Director requests a report from COD (US Department of Education Common Origination & Disbursement) for Direct Loans disbursed that month. That report is retrieved through EDConnect and reviewed. Financial Aid Director generates a report from Jenzabar Financial Aid system of Direct Loans disbursed for that month. The Financial Aid Director also retrieves a report of Direct Loans applied to students' accounts for that month from Business Office Senior Accountant. These three reports are then compared and reconciled for each month. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: Beginning 10/1/2023 (after first month of disbursement)

Finding Number: 2023-004 Condition: The Seminary did not maintain appropriate documentation to substantiate the allowable charges on the student's ledger account to identity whether credit balances were created and required additional documentation from the student to hold the credit balance Planned Corrective Action: Beginning with the Fall 2023 term, Title IV credit balances are no longer held past the 14 days with authorization from the student. The Financial Aid Director implemented a new policy where students cannot request that these funds are retained beyond 14 days. There is a shared list where the Business Office enters the date that the students’ credit balance was released to verify that process happens within 14 days. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/20/2023 (first day of Fall disbursement)

Finding Number: 2023-002 Condition: Of the 19 students who received disbursements selected for testing, the Seminary did not notify any of the students or parents, as applicable, that received direct federal loans within the required 30 days. Planned Corrective Action: Directly after a students’ Direct Loan is disbursed, Financial Aid Director manually sends the loan disbursement notification email to the student (through the Jenzabar financial aid system), which specifies the amount that they borrowed for the term and the right to cancel the loan within 14 days by emailing the Financial Aid Office. This email is recorded in the Jenzabar Financial Aid system. The Financial Aid Director also created a spreadsheet to track Direct Loan disbursements and notifications each term. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/20/2023 (first day of Fall disbursement)

Finding Number: 2023-007 Condition: The Seminary did not identify or provide the appropriate notification to a student that was not meeting the Seminary's policy on satisfactory academic progress (SAP). Planned Corrective Action: Satisfactory academic progress is now being monitored more carefully. The Satisfactory academic progress report is run out of the student financial aid system. The internally generated report is reviewed by the Registrar and Financial Aid Director to confirm that student satisfactory academic progress statuses are correct. Once the appropriate status is confirmed, the Financial Aid Director will document students who are not in compliance with the institution’s policy and provide notifications to each student through email. The emails are recorded in the students' Jenzabar financial aid account. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 06/01/2024

Finding Number: 2023-003 Condition: The Seminary did not have controls in place to identify and document the students who have withdrawn and the applicability of performing a return of Title IV funds. Planned Corrective Action: Financial Aid Director has established a procedure to ensure that R2T4 calculations are completed and any funds due to be returned are sent back to the Department of Education within 45 days of the date of the student's withdrawal. The Financial Aid Director created a listing to track all student withdrawals (including details of withdrawal). The Registrar sends an email to the Financial Aid Director notifying when a student has withdrawn from the institution, which gets entered onto the list. The Financial Aid Director set up the Department of Education's R2T4 calculator for the 2023-2024 academic year. R2T4 calculations are completed for any student withdrawn and if necessary, funds are returned to the Department of Education. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/05/2023 (beginning of Fall 2023 term)

06/30/2023 Corrective Action Plan Reference Number: 2023-001 Program Information: Student Financial Assistance Cluster – Federal Direct Loan Program, Federal Pell Grant Program Contact Person: Donna Lane Anticipated Completion: 08/30/2024 Fiscal year in which finding occurred: 2023 Condition Certain students with enrollment changes were not timely transmitted to National Student Loan Data System (“NSLDS’). Management View Management recognizes the importance of reporting enrollment status changes in a timely manner for lenders and servicers of student loans to determine in-school status, deferments, grace periods, and repayment schedules, as well as the federal government’s payment of interest subsidies. Corrective Action The University has taken the following steps to improve the accuracy and timeliness of enrollment reporting with respect to federal requirements: • In addition to the National Student Clearinghouse’s implementation of new password reset requirements, the University will verify the staff representatives on the NSC FTP-site communication list are current. The NSC Enrollment Reporting procedures have been updated to include the FTP communication list and the steps to add or remove members if there are staff changes in the future. • For students who initiate a withdrawal prior to the end of the spring term, the Registrar’s Office will maintain a list to submit manual updates after the final spring enrollment file has been processed. This will ensure timely reporting of the withdrawal without overwriting the spring enrollment submission. • Summer withdrawals will now be reported directly to NSC at the time of withdrawal, ensuring timely and accurate reporting. The Registrar's Office will submit a manual enrollment status change to NSC.

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658 As indicated in the Condition section of the finding, although the documentation related to safety considerations at child care institutions was not initially maintained in the official licensing files for 10 of the 40 cases tested for eligibility, the documentation was eventually provided to the auditors for eight of those 10 cases. For one of the remaining two cases, the child care institution is an out-of-state institution that is no longer in business. For the other case, the child care institution provided documentation, but the documentation did not include the dates of the institution’s safety checks. In an effort to enhance internal controls over the safety considerations at child care institutions, the West Virginia Department of Health and Human Resources, Bureau for Social Services (BSS), is continuing to analyze the condition that led to this finding and is considering a number of steps, including but not limited to the following as an immediate plan of action: • Transmit a copy of 2 CFR 1356.30(f) to all licensing personnel, supervisors, and other applicable staff within the BSS and oblige them to acknowledge that they have read and understand the requirements referenced therein. • Implement a formalized policy and develop written procedures for ensuring the licensing files for child care institutions contain documentation which verifies that safety considerations with respect to the staff of the institutions have been addressed. • Develop overall standards for the maintenance of documentation within licensing files (e.g., a consistent naming convention for the documents, which would improve internal tracking and ensure that requests from independent auditors are addressed efficiently and fully; personnel who have read-only access to documents versus those who can add, replace, and delete documents; record retention requirements; etc.). • Establish a formalized process for monitoring. Such a process would include a strategy for conducting internal reviews of all licensing files on a recurring basis, reporting the results of those reviews to appropriate officials internal and external to the DHHR, following up with those officials as may be necessary, and documenting the overall results accordingly. For example, if the results of a monitoring review indicated noncompliance [or potential noncompliance] on the part of a child care institution, the BSS would inform the institution, request a copy of the institution’s written policies and procedures regarding safety considerations, discuss it with the institution, and provide technical assistance to the maximum extent practicable. Once the BSS drafts the aforementioned policies and procedures and related monitoring process, or otherwise enhances their internal controls over the safety considerations at child care institutions, the BSS will discuss the matter with their regular programmatic contacts at the U.S. Department of Health and Human Services, Administration for Children and Families, and will ask the ACF if the BSS’s planned controls are aligned with the ACF’s universal expectations surrounding 2 CFR 1356.30(f).

ALLOWABILITY AND SPECIAL TESTS AND PROVISIONS – PAYMENT RATE SETTING AND APPLICATION Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658 The West Virginia Department of Health and Human Resources, Bureau for Social Services (BSS), will address the underpayment in question, which was $268.84. The BSS will also revise its training program for child welfare workers to include information regarding demand payments and pro-rating stays in foster care. To accompany the training, the BSS will also develop a desk guide for all child welfare workers and related staff, which will indicate the common monthly rates and pro-rated daily rates along with a contact person to assist with questions concerning any uncommon rates and other pertinent matters.

INFORMATION TECHNOLOGY GENERAL CONTROLS – WVPATH Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658, 93.659 The DHHR, Office of Management Information Services (OMIS), analyzed this finding and hereby offers more details into the condition and cause of the finding. The information technology system in question is named WVPATH, which stands for, “West Virginia People’s Access to Help.” WVPATH is a comprehensive social services/child welfare information system, allowing employees to more efficiently track and view data, streamline services, and ultimately improve the manner by which the State determines eligibility for programs and provides for the delivery of services. With respect to the Foster Care and Adoption programs, the WVPATH system replaced the “Family and Children’s Tracking System” (FACTS). The DHHR transitioned from FACTS to WVPATH in January 2023, which was approximately six months into fiscal year 2023. Fieldwork for the information technology portion of the West Virginia Single Audit began in June 2023. During fieldwork, the auditors inquired about the information technology general controls (ITGCs) within the WVPATH system. In particular, the auditors requested a description of the controls along with a copy of the policies, procedures, system generated listings, screenprints, and other documentation related to information security and access administration, change management, and backup recovery and restoration. Although the OMIS is of the opinion that the State of West Virginia indeed implemented all logical access and change management controls to support effective ITGCs over the WVPATH system, the OMIS did not address the auditor’s request in a timely manner during fieldwork. Therefore, the auditors were unable to determine whether the controls were designed sufficiently, nor were they able to conduct the requisite testing to confirm that the controls were in place and operating effectively during the applicable months of the audit period.   Upon receiving this finding, the OMIS conferred with the State’s third-party software vendor for the WVPATH system; prepared a description of controls; collected the documentation related to information security and access administration, change management, and backup recovery and restoration within the WVPATH system; and submitted the description of controls and related documentation to the auditors. On February 14, 2024, a meeting was held between the auditors, the OMIS, the third-party software vendor, and one of the audit coordinators from the DHHR central finance level. The purpose of the meeting was to discuss this finding and determine whether the documentation collected by the OMIS after fieldwork would have averted the finding in the first place. During the meeting, the auditors indicated that the description of controls is very detailed and appears to support the OMIS’s assertion that the controls are designed sufficiently. However, since the documentation was submitted to the auditors after fieldwork was complete, there was not enough time for the auditors to conduct the requisite testing to determine whether the processes and controls were in place and operating effectively during the applicable months of the audit period. In terms of a corrective action plan for this finding, the OMIS now has a greater understanding of the auditor’s objectives and procedures surrounding ITGCs. During fieldwork for the [forthcoming] West Virginia Single Audit for the year ended June 30, 2024, when the auditors are ready to test the required logical access and change management controls that are required to be in place to support effective ITGCs for the WVPATH system, the OMIS will undoubtedly be prepared to provide the auditors with a description of the controls along with a copy of all documentation related to information security and access administration, change management, and backup recovery and restoration within the WVPATH system.