Corrective Action Plans

3/30/2023 Grant Thornton 10 Almaden Blvd., Suite 800 San Jose, CA 95113 RE: Management?s Corrective Action Plan in Response to Fiscal Year 2022 Item 2022-001 ? Significant Deficiency ? Reporting: Special Reporting 1. Contact person: Syble Allen, Controller 2. Plan of action: The Controller, Director of Institutional Research and Student Accounts Director will all be given copies of the prepared FISAP for review and comment at least 3 days prior to FISAP submission each October 1. 3. Anticipated completion date: This new process will be implemented April 1, 2023.

Finding 2022-002 ? Information Technology General Controls Identification of the federal program: Federal Program: Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing No. 84.063) and Federal Direct Student Loans (Assistance Listing No. 84.268) Federal Agency: United States Department of Education BJC HealthCare Location: Goldfarb School of Nursing Award Periods: January 1, 2022 through June 30, 2022 (included in award year July 1, 2021 through June 30, 2022), and July 1, 2022 through December 31, 2022 (included in award year July 1, 2022 through June 30, 2023) Views of responsible officials and planned corrective actions: BJC HealthCare agrees with the findings as reported. GSON is committed complying with program requirements and meeting program objectives as defined in Section 200.303(a) of the Uniform Guidance, regarding auditee internal controls. To facilitate these requirements, GSON formalized a policy and procedure document regarding access controls to support effective information technology general controls (ITGCs) for the Banner application. A formal user access review will be completed semi-annually and results of the review, including actions taken, will be formally documented. Responsible Parties: David Solovitz, Interim Director Information Technology, Goldfarb School of Nursing Completion Date: The corrective action plan was implemented in Q3 2023.

Finding 2022-001 ? N4. Enrollment Reporting Identification of the federal program: Federal Program: Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing No. 84.063) and Federal Direct Student Loans (Assistance Listing No. 84.268) Federal Agency: United States Department of Education BJC HealthCare Location: Goldfarb School of Nursing Award Periods: January 1, 2022 through June 30, 2022 (included in award year July 1, 2021 through June 30, 2022) and July 1, 2022 through December 31, 2022 (included in award year July 1, 2022 through June 30, 2023) Views of responsible officials and planned corrective actions: BJC HealthCare agrees with the findings as reported. The Goldfarb School of Nursing is at Barnes-Jewish College (GSON) is committed to ensuring that student enrollment changes are reported accurately and timely to the National Student Loan Data Systems (NSLDS) in accordance with federal regulations. Procedures and processes have been implemented (to date) to address and correct GSON enrollment reporting compliance. To facilitate the completeness of the enrollment reporting process, the following steps will be incorporated into the GSON?s procedures: ? A second-tier review of student enrollment status reports (SFRNSLC), as prepared by the GSON Registration Technical Specialist, will continue to be completed by the GSON Registrar before submission of data to the National Student Clearinghouse (NSC). The GSON Registrar will randomly select a sample of students to compare enrollment report data to the student information system (Banner) and document their findings. This control was implemented in October 2022. Responsible Parties: Kristina Rieger, Registrar, Goldfarb School of Nursing at Barnes-Jewish College Edward Gricius, Associate Dean, Student Experience & Development, Goldfarb School of Nursing at Barnes-Jewish College Completion Date: The corrective action plan was implemented in October 2022.

BRIGHAM YOUNG UNIVERSITY-HAWAII Management's View and Corrective Action Plan Finding 2022-001- Non-Compliance with Timely and Accurate Student Enrollment Change Submissions to the National student Loan Data System (significant Deficiency) Grantor: U.S. Department of Education Program : Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant program Award Years: 7/2021 - 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan Corrective Action Plan: Due to the NSLDS outage as announced by the U.S. Department of Education Federal Student Aid's (FSA) office, we were unable to submit enrollment rosters for the period of July 19,2022 through February 28, 2023. Therefore, we are continuing to implement the following corrective action plan to address both the prior year and current year issues as discussed below. The current year finding is the result of three separate reporting issues. The first issue is a repeat finding from the 2021 fiscal year audit (2021-001) related to inaccurately reporting the status of graduated students. When graduation files were sent to the National Student Clearinghouse (NSC), many could not be processed due to the "G" status not being applied when students were reported as graduated. Because of this, the NSC was not sending graduation information for some students to the National Student Loan Data System (NSLDS). Therefore, to appropriately resolve this issue, Daryl Whitford, Registrar, will regularly access the NSC dashboard, prior to submitting of monthly enrollment report, to promptly identify and resolve any reporting issues to ensure NSLDS has the correct information for students. The second issue is a repeat finding from the 2021 fiscal year audit (2021-001) and is the result of inappropriate configuration of each semester's credit load determinations (i.e., how many credits constitute full time, three quarter time, half time, etc.) into PeopleSoft. As a result of the inappropriate configuration, certain student statuses were reported incorrectly given the number of credit hours the student was attending. To ensure accuracy of each semester's credit load determinations, at the beginning of each semester, Daryl Whitford, Registrar, will review and approve the credit load determinations prior to them being pushed into PeopleSoft. This will ensure that PeopleSoft is configured to communicate the appropriate statuses to the NSLDS. The third issue referenced the reporting of the correct program begin dates. When a student returns from a leave of absence or an internship, PeopleSoft updates the students program begin date for the students return date rather than the original program begin date. Daryl Whitford, Registrar, will perform a review of program begin dates for students returning from a leave of absence to ensure the proper program begin date is reported. In addition, we will review if any PeopleSoft enhancements can be made to provide additional comfort that the program begin dates are accurate in these circumstances. Daryl Whitford, Registrar, who is responsible for enrollment reporting at Brigham Young University- Hawaii will continue to provide training to staff who participate in enrollment reporting to ensure that they are aware of the campus and program enrollment changes to be reported, the details to be reported for each change, and the importance of submitting changes timely. Also, Daryl Whitford, Registrar, will oversee the implementation of a control wherein the University will sample students from each roster submission and trace the information from the batch file back to the supporting documentation to ensure that the information included in the batch roster file is accurate. Timing: Daryl Whitford, Registrar, will be responsible to oversee that the items as noted in the Corrective Action Plan section above will be implemented by July 1, 2023. Signed and Acknowledged Daryl Whitford Registrar

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan This issue is a result of no manual or system controls in place to prevent disbursement of financial aid to a student?s account if a student?s federal financial aid award notification was not yet communicated. This issue was corrected as soon as it was identified by changing our procedures to require Pell notification letters be sent as soon as funds are awarded and before funds are disbursed to a student?s account. As an additional precaution, Pell notification letters will be added to the nightly batch process in PeopleSoft to ensure letters are sent timely. Financial aid staff will also receive additional training in this area. Timing Procedures will be changed in May 2023 by Riley Niemand, Manager of Financial Aid, to require Pell notification letters be sent as soon as funds are awarded and prior to funds being disbursed to a student?s account. During May 2023, Riley Niemand will also provide additional training to financial aid staff in this area. Additionally, Riley Niemand started working with a consultant to add Pell notification letters to the daily batch process. This work is expected to be complete by June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan The prior year corrective action plans were successful in addressing the issues identified in previous audits in enrollment reporting. These additional steps will be taken to address the new issues found during the 2022 audit within enrollment reporting, which resulted in a repeat finding of 2021-001. Grayson Layton, Registrar, will review the College?s policies and procedures surrounding student enrollment and enrollment reporting, starting in May 2023 specifically as it relates to students that have withdrawn that are expected to return in the subsequent semester but fail to reenroll. Any changes in the College?s policies and procedures will be appropriately documented and communicated to the individuals involved in updating student enrollment information in the system. Additionally, Enrollment Services will work with a PeopleSoft consultant and technical staff to customize our Student Information System to allow for the correct reporting of student status to the National Student Clearinghouse (NSC). Technical staff and a consultant will be engaged to perform an evaluation of all systems and practices related to enrollment reporting. The Enrollment Services and Financial Aid and Scholarships Offices will use various NSC and National Student Loan Data System (NSLDS) error reports to ensure student enrollment information, including program level information, is reported in an accurate and timely manner. Timing Grayson Layton, Registrar, will work with consultants and technical staff starting in May 2023 to begin making necessary adjustments to the Student Information System to allow for accurate reporting of student enrollment information and to evaluate systems and practices related to enrollment reporting. They will meet monthly throughout the year to monitor their progress with an expected completion in December 2023. Grayson and Riley Niemand, Manager of Financial Aid, will coordinate the use of NSC and NSLDS error reports to identify students with reporting errors. This process will be complete in June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University review internal control reports and implement review controls for work performed by third party servicers. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University is already utilizing Visual Compliance to assess all vendors for suspension and debarment but will obtain and document the review of the SOC 2 report for Visual Compliance annually. Name(s) of the contact person(s) responsible for corrective action: Scott Schlotthauer, Chief Procurement Officer at Oklahoma State University. Planned completion date for corrective action plan: December 2023

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the student financial aid department review its current procedures for evaluating students that did not receive a passing grade in a term to ensure enrollment status changes are determined timely and accurately. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. Procedures are being updated to ensure enrollment changes for students who did not receive a passing grade in a term will have their enrollment status changes reported timely and accurately. Name(s) of the contact person(s) responsible for corrective action: Sheila McGill Executive Director, Financial Aid & Scholarships, Langston University. Planned completion date for corrective action plan: January 2024

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University review its current procedures for Title IV funds and implement additional procedures to ensure refunds are returned timely. We also recommend the University implement formal review procedures to document the Return of Title IV calculations are being performed to minimize the likelihood that errors may go undetected and not be corrected in a timely manner. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. Procedures for review and return of Title IV funds are being updated to ensure refunds are returned in a timely manner. Return of Title IV calculations are being documented and reviewed by a party independent of the preparer to minimize the likelihood that errors go undetected and/or not be corrected in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Sheila McGill Executive Director, Financial Aid & Scholarships, Langston University. Planned completion date for corrective action plan: January 2024

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend that the student financial aid department work to ensure disbursements are reported to COD within 15 days of the disbursement date and that disbursements date reported in COD matches the disbursement date to the student. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. Updated procedures are in place to ensure disbursements are reported to COD in a timely manner in accordance with Federal guidelines. Name(s) of the contact person(s) responsible for corrective action: Sheila McGill Executive Director, Financial Aid & Scholarships, Langston University. Planned completion date for corrective action plan: January 2024

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported timely and accurately. Action taken in response to finding: The University agrees with the finding and has developed the following corrective action plan. The University will update its NSLDS reporting processes to ensure needed submissions are reported timely and accurately. Name(s) of the contact person(s) responsible for corrective action: Chris Kuwitzky, Vice President for Fiscal and Administrative Affairs, Langston University. Planned completion date for corrective action plan: March 2024

The DCFS is currently working with USDHHS’ Childrens’ Bureau (CB) on a Program Improvement Plan (PIP) related to Adoption Assistance subsidy payments. The PIP requires significant changes to DCFS’ policy that are still being vetted by CB and DCFS management, which will have a significant impact on how this program is carried out. As soon as the policy changes are completed, the DCFS will finalize procedures consistent with policy, the Social Security Act, and Title IV-E. These procedures will include controls to ensure payments made are appropriate per the subsidy agreements with the adoptive parents and federal requirements. In the meantime, the DCFS will be implementing the following: 1. The DCFS is revising the communication with adoptive parents reminding them of their responsibility to inform the DCFS of situational changes that could affect the subsidy agreement. 2. The DCFS is amending its adoption agreement template to more clearly define how and when an adoption subsidy can be suspended or terminated by the DCFS. 3. The DCFS’ Policy, Legal, Quality Assurance, Finance and Adoptions Administration divisions are currently reviewing all forms and policy documents to ensure they are consistent in communicating the preceding steps. The DCFS will include definitions of legal responsibly and financial support to establish the parameters of suspension or termination of subsidy payments. There has been significant progress in this area that has resulted in significant policy changes that are being finalized with assistance and input from the CB. 4. The DCFS will amend its Title IV-E plan related to adoption subsidy payments to include definitions consistent with item 3 above. 5. The DCFS will review its processes, including its information systems, to determine if information captured by permanency case workers can be data mined for review to support continued adoption subsidy payments. 6. The DCFS is creating communication procedures related to appeal decisions of termination and suspension of subsidy payments to adoptive parents to ensure they are aware of their rights to appeal and how the appeal process works.

As of June 30, 2022, the portfolio was transition. Thus, no further corrective action is considered necessary.

There is a myriad of activities and timing issues that can impact awards and ultimate disbursements. In some cases, the dependency status can change as FAFSA and corresponding loan forms are revised. The Financial Aid department is committed to review internal processes and system rules to ensure that the Banner packaging process is set up to catch changes in dependency status and awards accordingly. Responsible Person: Director of Financial Aid (Mitch Dedor) Completion Date: December 2023

Due to high turnover within multiple departments tasked with administering Financial Aid and the time required for the training of new staff on the aid disbursement process, errors were made due to lack of knowledge of the rules. Training and verification of information at every level is a top priority. The staff now has a much better understanding of the process and rules concerning awards. In addition, the director’s are actively working on improvements to the ERP system, “Banner”, so that errors that were due to human activities are reduced or eliminated. Already several processes, such as confirming attendance for aid posting is automatic. Now, more than one staff member is trained and responsible for processes and the team has consistent scheduled follow-up meetings on key actions in this area. Responsible Person: Director of Financial Aid (Mitch Dedor) & Registrar (Amanda Koci) Completion Date: December 2023

Assistance listing number and program name: 93.658 Foster Care – Title IV-E 93.658 COVID-19 Foster Care - Title IV-E Agency: Department of Child Safety Name of contact person and title: Emilio Gonzales, Audit Administrator Completion date: June 30, 2024 Agency’s Response: Concur The Department will comply with the Federal Funding Accountability and Transparency Act (FFATA) and federal Uniform Guidance regulations in accordance with the Department’s Grant policies and procedures that include: • Identifying all subrecipient expenditure reports required for FFATA reporting. • Developing an expenditure template for the Federal Funding Accountability and Transparency Subaward Reporting System (FSRS). • Reporting the subrecipient expenditures in the FFATA Subaward Reporting System no later than month-end of the month following the subaward action. • Providing initial and annual training(s) to identified staff about FFATA Subaward expenditure submission. • Confirming FFATA Subaward Reporting System submission.

Assistance listing number and program name: 93.658 Foster Care – Title IV-E Agency: Department of Child Safety Name of contact person and title: Tanya Abdellatif, Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur Department will ensure background checks for childcare institutions’ employees are completed prior to their hire date by: • Reviewing and amending DCS 15-32 Background Checks – Child Welfare Agency Staff policy and procedures to clarify that Child Welfare Agencies shall request and receive results for DCS Central Registry background checks prior to employment/date of hire. • Revising the Personnel File Monitoring Tool for licensing to include language that background checks need to be completed prior to hire and ensure all Child Welfare Licensing staff are utilizing the updated checklist. • Implementing, as part of the Quarterly Site Visit Process for childcare institutions, a process to review backgrounds checks to identify opportunities for improvement, trends and establish actions (countermeasures) to resolve any areas of concern. Hiring processes for each agency will also be reviewed during the quarterly site visits. • Providing updates related to policies and procedures during Quarterly Provider Meetings for childcare institutions, implementing monthly provider calls/meetings and conducting monthly unit/team meetings for Department. • Presenting the safety requirement expectations related to background checks for employees to childcare institutions and how the safety requirements are necessary for foster care maintenance payments at a quarterly meeting. • Conducting monthly monitoring of childcare institutions’ compliance with safety requirement expectations (background checks) for new and existing employees for fiscal year 2023.

Assistance listing number and program name: 84.425E COVID-19 Education Stabilization Fund—Higher Education Emergency Relief Fund (HEERF)—Student Portion Student Financial Assistance Cluster 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study 84.038 Federal Perkins Loan Program—Federal Capital Contributions 84.063 Federal Pell Grant Programs 84.268 Federal Direct Student Loans 84.379 Teacher Education Assistance for College and Higher Education Grants (TEACH Grants) 93.364 Nursing Student Loans 93.925 Scholarships for Health Professions Students from Disadvantaged Backgrounds—Scholarships for Disadvantaged Students (SDS) Agency: Northern Arizona University (NAA) Name of contact person and title: Bradley Miner, Interim Associate Vice President and Comptroller Anticipated completion date: November 30, 2023 Agency’s Response: Concur See University response section at the end of this report for the corrective action response for finding 2022-126.

This Repeat Finding has been acknowledged and corrective action is already in the process of being implemented. In November 2022, Union signed a Master Service Agreement with the National Student Clearinghouse (NSC) to perform enrollment and educational financial industry reporting, as well as education verification and authentication services. National Clearinghouse is the leading provider of educational reporting and data exchange, reporting on 97% of post-secondary student enrollments in the US. Union will be using a secure FTP process to send our enrollment data to NSC for timely and consistent reporting to the National Student Loan Data System (NSLDS). This Spring, Union completed the initial portion of the implementation by uploading a base set of enrollment data to NSC using Spring 2023 enrollment information. This was followed by one round of data clean-up. A second set of enrollment data was transmitted in December 2023. The Registrar and Financial Aid Director have been provided direct access to both NSC and NSLDS. As a backup, the Associate Dean of Academic Administration and Vice President of Admissions and Financial Aid have been granted NSC login credentials in order to ensure continuity of reporting in case of employee absence. The Registrar’s Office plans to begin regular monthly uploads of enrollment data to NSC beginning January 2024.

Children and Youth Programs Assistance Listing 93.090 Guardianship Assistance Assistance Listing 93.645 Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing 93.658 Foster Care Title IV-E Assistance Listing 93.659 Adoption Assistance Assistance Listing 93.778 Medical Assistance Program Assistance Listing 93.556 MaryLee Allen Promoting Safe and Stable Families Program Act 148 Pennsylvania Department of Human Services Views of the Responsible Officials and Corrective Action Plan: After a recent discussion with the [PA] Office of Children, Youth, and Families (OCYF), DHS was informed that compensation plans for FY21 and FY22 were on file and under review. However, approval was pending. OCYF explained that the State reviews plans on a calendar-year basis. However, city pay plans change during a July-June fiscal year. Therefore, the possibility of overages can occur because of salary increases or other personnel changes. The process is that once the new compensation plan is received, the reviewing authority would flag any items that are in excess of the existing approved rates. At that time, DHS would be permitted to submit a waiver for the items in question. Contact Person: Landuleni Shipanga, Controller, Department of Human Services, 215-683-6366.

A. Comments on Findings and Recommendations: 2022-003 – INCORRECT REFUND CALCULATION We agree with the finding for an incorrect refund calculation. B. Actions Taken or Planned: 2022-003 – INCORRECT REFUND CALCULATION The refund was calculated incorrectly and was caused by not including a scheduled break of 5 days or more due to the Thanksgiving holiday. This resulted in a refund being transmitted to the Department of Education that should have been retained by the college. The college will credit the $196 to the student’s account and in the future, a more thorough cross-check of the R2T4 will be performed by the Financial Aid office before processing the refund.

A. Comments on Findings and Recommendations: 2022-002 – LATE AUDIT We agree with the finding for a late audit. B. Actions Taken or Planned: 2022-002 – LATE AUDIT The Board’s Treasurer for 2022 was unable to assist with the 2022 audit due to a health concern. There was delay in getting the information needed to finalize the financial audit, which then delayed the federal direct loan program audit. This has been rectified with a former Board Treasurer rejoining the Board who has experience from prior years. The college will implement the necessary procedures to prevent future audits from being submitted late.

A. Comments on Findings and Recommendations: 2022-001 – FINANCIAL RESPONSIBILITY We agree with the finding for not meeting the minimum financial standards set forth by the DOE. B. Actions Taken or Planned: 2022-001 - FINANCIAL RESPONSIBILITY The organization incurred a net loss for the year as a result of additional expenditures related to opening a second location in Bradenton, Florida, and we don’t anticipate these additional expenditures in 2023. We anticipate having operations returning to normal and growing our enrollment with the addition of a second location.

Management’s Corrective Action Plan Finding number: 2022-002 Federal agency: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #’s 84.063, 84.268 Award year: 2022 Corrective Action Plan The BAC will augment last year’s monthly automation of roster submission with a monthly reconciliation of enrolment status as recorded in our student information system with the data recorded in NSLDS. Management will provide training to those reasonable for reporting enrolment status to NSLDS via the National Student Clearinghouse. This training will include the relevant rules and regulations as well as stress the importance of accuracy and the potential consequences of errors, both to our students and the institution. Timeline for Implementation of Corrective Action Plan The College plans to implement the corrective action plan by October 1, 2023. Contact Person James Ryan, Ph.D. Vice President of Enrollment Management

Arkansas Baptist College disagrees with the finding. NSLDS confirms that the student had not exceeded her Lifetime Eligibility of 600%. She used 571.765% of the 600% she was eligible to receive. Although NSLDS indicates her scheduled award amount is $6,495, she would exceed 600% if awarded the full amount. She was awarded $1,624 which brings per Pell Grant Annual and Lifetime Eligibility to 600%.