Corrective Action Plans

Incorrect and Late Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Upon the current finding of incorrect enrollment reporting to NSLDS, the Western Seminary Financial Aid office will seek to make three changes to its operational practices; integrating NSLDS reporting into a master calendar, institute standard practices in pulling withdraw data and create a training emphasis around proper withdraw practices. Person Responsible for Corrective Action Plan: Matthew Jolley, Director of Financial Aid Anticipated Date of Completion: 06/2023

Return of Title IV (R2T4) Calculations Planned Corrective Action: Upon the current finding of deficient Return of Title IV practices, the Western Seminary Financial Aid office will seek to make three substantial changes to its operational practices, integrate a master calendar integrating processing R2T4, institute standard practices in pulling withdraw data and create a training emphasis around R2T4. First, the Western Seminary Financial Aid Office will see to institute and integrate a Financial Aid Master calendar. This calendar will dictate when withdraw (0-credit) reports will be pulled for an evaluation to assess if a Return to Title IV is necessary. Secondly, the Financial Aid office will implement a standard procedure where the date of last participation is pulled from within the WISE system. The last date of participation data standard will be recorded and updated in the FA Policy and Procedures manual. Thirdly, the Financial Aid office will emphasize training on R2T4 with Attain consulting. Person Responsible for Corrective Action Plan: Matthew Jolley, Director of Financial Aid Anticipated Date of Completion: 06/2023

Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Compliance Requirement: Reporting Finding Summary: Management was unaware of the requirement to submit the annual proposed budget to the Rural Development Area Office within 30 days of each year end. The Hospital approves the budget annually. However, the budget is not submitted to USDA. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will put a process in place to ensure the approved budget is submitted to USDA within 30 days of year end. Anticipated Completion Date: December 31, 2023

Name of Responsible Individual: Lori Jenkins & Ruth Casper Corrective Action: The University Financial Aid Office has restructured the disbursement notification schedule as noted below: ? Disbursement notification letters are to be printed every 21 days. The federal requirement for notification is every 30 days. ? The Direct Loan Officer and Director of Financial Aid have access to create and print the letters. ? Electronic calendar notices for the disbursement notifications are sent to the Direct Loan Officer, Director of Financial Aid and the Asst. Vice President for Analytics & Audit. ? Task completion will be verified by the Asst. Vice President for Analytics & Audit on a monthly basis. Anticipated Completion Date: The disbursement notification schedule has been revised as of August 26, 2022.

Corrective Action: A two-person team has been developed to ensure USDA terms and conditions are followed. Both team members will be responsible for reviewing and understanding the terms and conditions of the USDA loans, including the reporting requirements and applicable deadlines. Each team member will be assigned to complete a specific requirement and the other member will independently review and acknowledge prior to submission. Person Responsible: Janet Soper, VP/CFO, Labette Health (620} 820-5251 janets@labettehealth.com Proposed Completion Date: July 20, 2023

Recomendation: Ongoing staff training of District and colleges Financial Aid staff related to implemented business process related to submission of information to NSLDS via NSC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Enrollment file reported to NSLDS is submitted on behalf of the District by the National Student Clearinghouse (NSC). The enrollment file is generated from the recently implemented ERP PeopleSoft data system. While the District submits its monthly enrollment reports as required, there have been some discrepancies between what the system reported and what was reported to the NSLDS. The District developed and implemented a business process to maintain documentation with the colleges Financial Aid Offices of what is submitted to NSC to ensure informafion is being reportted to NSLDS accurately. The NSC/NSLDS reporting process within PeopleSoft: Campus Solutions is a delivered process developed by Oracle and is used by most other institutions reporting to the NSLDS. Staff training will continuee to be conducted to emphasize the need for District and colleges staff to follow the existing processes and controls to ensure timely and accurate reporting to NSLDS.

Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in the Ave Maria School of Law and Ave Maria School of Law Foundation Single Audit Act Compliance report for the year June 30, 2022, and corrective actions to be completed. 2022-001 - Special Tests and Provisions - Enrollment Reporting Auditor Description of Condition and Effect. We noted that six students out of a testing population of 14 were not reported timely to NSLDS and did not have the correct status change reported. As a result of this condition, the Organization was exposed to an increased risk that incorrect and untimely information would be reported to NSLDS. Auditor Recommendation. We recommend that the Organization consistently apply their enrollment reporting procedures to prevent untimely status change reporting in the future. Corrective Action. Management concurs with the finding. The Organization will ensure the enrollment reporting procedures are being followed. Responsible Person. Kaye Castro Anticipated Completion Date: June 30, 2023

Finding: Washington State University did not ensure that returns of Title IV funds were accurate for the Student Financial Assistance programs. Questioned Costs: Assistance Listing # 84.007 84.033 84.038 84.063 84.268 84.379 Amount $2,582 Status: Corrective action complete Corrective Action: The University has improved processes for the return of Title IV funds. The University: ? Included a standard calculation in workbooks to quickly identify whether amounts to be returned for withdrawn students will exceed the amounts disbursed. ? Implemented a quality check to review these exceptions, and to investigate and correct as necessary. The University has returned all questioned costs to the sponsors. Completion Date: May 2023 Agency Contact: Heather Lopez Chief Audit Executive PO Box 641221 Pullman, WA 99164-1221 (509) 335-2001 hlopez@wsu.edu

Views of Responsible Officials and Corrective Action Planned: The Seminary is currently working on developing an Information Security Program in order to meet current and upcoming requirements of the Gramm-Leach-Bliley Act. The Seminary?s plan is to have this developed and implemented before December 9, 2022.

Views of Responsible Officials and Corrective Action Planned: The Seminary hired a third-party financial aid servicer, Financial Aid Services, LLC (?FAS?) who will do the enrollment reporting as part of their contract. The FAS contract was signed May 2022 for the upcoming fiscal year 2022 to 2023. This contract was approved by the Administrative Council in May 2022. The Seminary?s current part-time financial aid coordinator sent out the April 2022 enrollment roster which included student status changes on October 17, 2022.

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with reporting requirements for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department acknowledges that errors were made in the quarterly reports submitted during the audit period. The errors were identified by the Department and corrected in October 2022. The Department understands accuracy in reporting is vital. To address the audit finding and recommendations, the Department took the following corrective actions: ? The lead worker established three meetings each quarter with the Cost Allocation and Grants Director for processing the quarterly reports: o A pre-meeting to discuss the reporting requirements, o A meeting during the reporting process to review the final report prior to submission, and o A post reporting meeting to discuss any concerns encountered during the reporting process. ? Implemented a data verification process by management prior to submission of the quarterly reports. The Department is committed to improving internal controls over grant management activities and will continue to properly follow the grantor?s published instructions when completing the quarterly reports. Completion Date: October 2022 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure group care facility employees had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department partially concurs with the finding. The Department is committed to ensuring the health, safety, and well-being of all children in our care. As stated in the Effect of Condition on the audit finding, the auditors found all group care facility staff sampled during the audit had a cleared background check prior to working in the facility. While the Department agrees the use of definitions such as ?effective date? and ?start date? in FamLink could be misleading, the Department does not concur internal controls were not adequate to ensure group care facility employees had cleared background checks before having unsupervised access to children. The Department is confident that all staff who work with children and youth have cleared background checks. Effective April 1, 2023, the Department implemented a new process for processing background checks for group care facilities to strengthen internal controls, documentation, and clarification on the ?effective date.? The updated process is outlined below: ? A new form was created with clear instructions for the group care facilities to provide the applicant/employee information, including the background check confirmation code, directly to the Department?s Background Check Unit (BCU). ? The BCU works with the applicant/employee through the fingerprint background check process. ? The results are sent directly to the BCU at which time they complete a child abuse/neglect history check and, if needed, a suitability assessment. The BCU documents the results in FamLink with the date the background check is completed. ? The BCU emails the results to the group care facility and the Department?s Licensing Division (LD) group. If the applicant/employee is cleared and is not a renewal, LD staff adds the applicant/employee to the group care facility in FamLink with the clearance information attached. Completion Date: April 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action in progress Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. In response to the auditor?s recommendations, the Department will work with the Financial and Business Services Division and Foster Care Program to review the fiscal monitoring procedures to ensure payments to providers for travel and family visits are allowable and adequately supported. The conditions noted in this finding were previously reported in finding 2021-040. Completion Date: Estimated December 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Children, Youth, and Families did not have adequate controls over and did not comply with certain requirements of its Public Assistance Cost Allocation Plan. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department concurs with the finding and is committed to improving internal controls. During July through September 2021, the first three months of the audit period, the Department did not have adequate staffing levels to maintain the business processes for the Public Assistance Cost Allocation Plan (PACAP) cost base for administrative charges. Available staff focused on grant reconciliations and close-out of the prior fiscal year financial transactions. In October 2021, the Department began updating the monthly workbooks in accordance with the approved PACAP. To address the finding and audit recommendations, the Department: ? Reviewed the written base edit form procedures with staff. ? Added reminders for base edit entries to the Cost Allocation and Grants Management Unit calendar. Completion Date: April 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

U.S. Department of Education Community College District of St. Louis respectfully submits the following corrective action plan for the year ended June 30, 2022. Contact information for the individual responsible for the corrective action: Mark Swadener, Vice Chancellor of Finance Community College District of St. Louis 3221 McKelvey Road Bridgeton, MO 63044 Independent public accounting firm: KPM CPAs, PC, 1445 East Republic Road, Springfield, MO 65804 Audit Period: Year ended June 30, 2022 The finding from the June 30, 2022 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered with the number assigned in the schedule. Finding ? Major Federal Award Program Audit 2022-001 Recommendation: We recommend the College implement procedures in order to strictly comply with the requirements of 34 CFR 682.610 and 685.309 as it relates to reporting required to the NSLDS. We further recommend that the College follow the guidance provided in the NSLDS Enrollment Reporting Guide and stay abreast of new guidance as published by the Department of Education. Corrective Action Taken: The Office of the Registrar at Saint Louis Community College investigated he exception and updated our existing reporting procedures beginning with the Fall 2022 semester. The College believes the new procedures will timely identify and report the required enrollment status changes for the National Student Loan Database System (NSLDS). Anticipated Completion Date: Fall 2022 semester

Management's response to Finding 2022-002 Significant Deficiency- Student Status Changes Response: Bethany College accepts the finding that we have had an unplanned lapse in our enrollment reporting to NSLDS. This lapse is attributable to Bethany's monthly reporting to the National Student Clearinghouse. The National Student Clearinghouse information is submitted through the Student Status Confirmation Report process. The records are then updated with NSLDS. Due to transitions in the positions responsible for the reporting, the monthly uploads were not timely and resulted in sequent errors. Additionally, Bethany has had transitions in other offices that led to some of the identified issues regarding graduation dates and withdrawals. Due to the transitions, Lisa Reilly, Associate Provost of Academic Records and Accreditation, is now a key holder in the system. She had received training from the consortium that Bethany participants in for its database and has been working with National Student Clearinghouse on reports and updating student information. Two additional individuals will be identified and trained to process these reports by June 30, 2023. The institution will prepare a standard guide that will be used in the case of any transitions to prevent this this repeated pattern. The training guide will be completed by June 30, 2023. Reilly is working with National Student Clearinghouse on these corrections and aims to have them completed by March 31, 2023. By December 2023, Bethany will establish an internal audit of the submissions during this period of transition.

Finding 2022-003: Enrollment Reporting Award Information Cluster: Student Financial Assistance Agency: Department of Education Award Name: Federal Direct Student Loans, Federal Pell Grant Program Award Year: July 1, 2021 ? June 30, 2022 Assistance Listing Numbers: 84.268, 84.063 In August 2021, prior to the Workday Student implementation "go live" in September 2021, the University was working with their implementation consultants to help with the initial configuration of enrollment reporting in Workday. Since implementation, they have been continuously making updates to the system and processes to prevent errors from occurring. The Registrar?s office has spent significant time working to understand and refine the way that enrollment status data is captured and processed in the system. The Registrar's Office works collaboratively with partners on campus (Financial Aid and Information Technology) on identifying and resolving issues. After turnover and an extended vacancy in the Assistant Registrar position, the new Assistant Registrar started in July 2022, took over the reporting and has worked diligently to more timely identify and address errors and has noted a decrease in the number of system errors and data kickouts as a result of this work. In addition, in September 2022 the University engaged an NSC Data Specialist with Workday Student expertise to help monitor and ensure that issues are identified promptly and resolved. The Registrar?s office continuously monitors and implements Workday system updates to ensure that our system is up-to-date and staff are informed of challenges that are being identified in the larger Workday community. Finally, the Registrar?s Office continues to work closely with its financial aid counterparts, including their Director of Systems, Reporting, and Compliance, to ensure data is processed and reported within the Federal Guidelines. The last phase of this work is finalizing our review of the process and data related to degree transmission, such work as is expected to be completed no later than May 2023. The Assistant Registrar, James Smith, who can be reached at datarequest@simmons.edu, is responsible for the implementation of this corrective action plan.

Management?s Views and Corrective Action Plan The University implemented two new systems (Student Information System ? Workday, and Financial Aid System ? PowerFaids) that each are an important part of managing our Federal Student Aid. Most of the building and configuring of these systems happened prior to FY22 with the full launch in production taking place for the Fall 2021. Understandably, some of the integrations of these two systems were not able to be tested prior to Fall of 2021 (ex: actual disbursement of federal loans) and therefore, required significant time and effort in the Fall and beyond to ensure everything worked and students were able to receive funding while also building out and documenting required communications, processes, and compliance protocols. Additionally, we had turnover within the Associate Director of Financial Aid and Loan Manager role in March 2022. The implementation coupled with this staffing issue created a one-time set of circumstances that are outside of the standard oversight and management of our Federal Student Aid funds and processes. Please refer to the response to each individual finding as follows: Finding 2022-002: Borrower data and reconciliation reporting Award Information Cluster: Student Financial Assistance Agency: Department of Education Award Name: Federal Direct Student Loans Award Year: July 1, 2021 ? June 30, 2022 Assistance Listing Number: 84.268 As mentioned above, the University implemented two brand new systems (Student Information System ? Workday, and Financial Aid System ? PowerFaids) that each are an important part of managing our Federal Student Aid. During the first month of the Fall term there were significant challenges with the communication between these systems, which resulted in our first group of loans being disbursed in the last few days of September 29, 2021. It is a known issue that any loans that disburse at the end of the month are not included in the Federal SAS Reconciliation file and as a result this disbursement resulted in significant errors. Ultimately, the University was not able to finalize this reconciliation for this month. As mentioned above, the Financial Aid Office was restructured to provide even greater oversight over our Federal funds. Under the restructured office, the new Associate Director and Manager of Loans and Pell Grants has documented all processes, including reconciliation. Additionally, we created an automated report that is generated after the SAS is received and loaded into PowerFaids. A notification is sent to both the Associate Director/Loan Manager as well as the Director of Financial Aid Systems, Reporting and Compliance to provide documentation that the report was run. The Loan Manager reports to the Director of Financial Aid Systems, Reporting and Compliance who signs the completed SAS reconciliations. This process was fully put into place, including signature, for the 2022-2023 academic year beginning with the September 2022 Reconciliation. The Director of Financial Aid Systems, Reporting and Compliance, Amanda Galban, who can be reached at amanda.galban@simmons.edu, is responsible for the implementation of this corrective action plan.

Management?s Views and Corrective Action Plan The University implemented two new systems (Student Information System ? Workday, and Financial Aid System ? PowerFaids) that each are an important part of managing our Federal Student Aid. Most of the building and configuring of these systems happened prior to FY22 with the full launch in production taking place for the Fall 2021. Understandably, some of the integrations of these two systems were not able to be tested prior to Fall of 2021 (ex: actual disbursement of federal loans) and therefore, required significant time and effort in the Fall and beyond to ensure everything worked and students were able to receive funding while also building out and documenting required communications, processes, and compliance protocols. Additionally, we had turnover within the Associate Director of Financial Aid and Loan Manager role in March 2022. The implementation coupled with this staffing issue created a one-time set of circumstances that are outside of the standard oversight and management of our Federal Student Aid funds and processes. Please refer to the response to each individual finding as follows: Finding 2022-001: Returns of Title IV Funds Award Information Cluster: Student Financial Assistance Cluster Grantor: Department of Education Award Name: Federal Direct Student Loans Award Year: July 1, 2021 ? June 30, 2022 Assistance Listing Number: 84.268 In implementing PowerFaids we were required to set up our own Selection Sets (set group of criteria) for managing all of the disbursements (positive or negative) for each type of fund. For all of our loan funds, we used criteria that included requiring that the particular term have at least half-time enrollment. We used this selection set to disburse (increase or decrease) both the loan to the Student Account (in Workday) as well as to get on the Books with FSA (through COD). We realized that students who took a Leave of Absence or Withdrew from the University needed their own selection set because they would have been updated to have zero credits in the term they took a leave or withdrew. The two instances where we were late in adjustment, we were in the middle of the staffing situation. Documentation had not been written by the Loan Manager at that time. Once we identified the issue with the selection set for students who were withdrawn or on a leave of absence, we reviewed all students with this condition, corrected refunds as appropriate and ensured this was corrected moving forward. The Director of Financial Aid saw a need to have greater oversight on our Federal Funds. She began a process of restructuring the Office as of February 21, 2022 so that the Loan Manager position no longer had direct reports and their main responsibility is the management of federal and private loan portfolios and the federal Pell grant fund. Processes have been documented and all selection sets and processes are managed by this new Associate Director (Loan Manager) who now reports directly to the newly created Director of Financial Aid Systems, Reporting and Compliance April 21, 2022. We do not foresee further issues with return of funds within the required 45-day timeline. The Assistant Vice President, Enrollment Student Services & Director of Financial Aid, Amy Staffier, who can be reached at amy.staffier@simmons.edu, is responsible for the implementation of this corrective action plan.

The College?s Financial Aid office has instituted a reconciliation process that is now completed monthly, with timely and appropriate levels of review of the reconciliations. All previous month?s reconciliations were performed and reviewed, and the monthly reconciliation process is now part of the standard month-end procedures.

Federal Award Findings and Questioned Costs Finding: 2022-001 Name of Contact Person: Karen Harrington, DSS Director Corrective Action/Management?s Response: Agency agrees with the finding and will ensure random reviews of workstations will be completed. Agency will ensure immediate refresher in Unit meetings regarding computer security. Additionally, County DSS will continue with an annual training to review computer security and will ensure computer security is addressed in new employee orientation. Proposed Completion Date: Immediately and ongoing.

Non-Compliance ? Failure to Undergo the Required Single Audit Description of Finding: The auditor found that The Entity did not obtain the required single audit for the year ending September 30, 2021. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: Management has obtained the required Single Audit for the year ending September 30, 2022, the year in which the interim construction loan was refinanced by the direct loans from the Rural Utilities Service. Management was unaware that the expenditures of the interim construction loan were considered federal expenditures. All of the federal award activity during the September 30, 2021 and 2022 fiscal year ends have been audited as a part of the September 30, 2022 Single Audit. Management will review loan agreements, communicate with oversight agency officials, and consult annually with external auditors about requirements for single audits in the future.

The Controller?s office will implement a process in which an individual will formally document their review of the third-party servicer?s most recent Title IV compliance audit in a memorandum. The memorandum will then be reviewed by another individual other than the preparer. Tara Thomason, Controller and Assistance Vice President, is responsible for addressing the above items by December 2023.

The University will continue to work with our Information Technology to update the process. Matching with the current process for parent loan notification is the initial step. That process does include but does not fully rely on a trigger in the student system communication forms. (no parent loan citing). In an overall process improvement, the goal is to move out of the webfocus engagement to a new automated process. Cari Wickliffe, Assistant Vice President and Director of Student Financial Services, is responsible for addressing the above items by July 1, 2023

The University will implement a two-step review internally to ensure records are reviewed within the required days. The University is filling vacant positions and reviewing additional operations support. Additionally, most of the errors occurred when a student did not answer completely or correctly the high school graduation information on the Free Application for Federal Student Aid (FAFSA), questions 26 and/or 27. The system is set to hold any loan disbursements if this question and associated C Flags are present. Pell disbursement, however, bypasses this control. The University has established a procedure to identify in the extract log errors from attempting to disburse. A hold will be placed on the student account, and if any Pell disbursement is not fully accepted, it will be reversed. Cari Wickliffe, Assistant Vice President and Director of Student Financial Services, is responsible for addressing the above items by August 1, 2023