Corrective Action Plans

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Recommendation: Western Connecticut State University should strengthen internal controls to ensure that it submits enrollment status changes to the National Student Loan Data System in accordance with federal regulations. Corrective Action Plan as Reported by Western Connecticut State University: We...
Recommendation: Western Connecticut State University should strengthen internal controls to ensure that it submits enrollment status changes to the National Student Loan Data System in accordance with federal regulations. Corrective Action Plan as Reported by Western Connecticut State University: We agree with this finding. The discrepancy was originally identified during the first Gainful Employment / Financial Value Transparency (GE/FVT) submission in 2024, when Clearinghouse program lengths did not match NSLDS data. To ensure accurate reporting, the School Deans reported correct program lengths to the Registrar’s Office who implemented program-specific duration rules in the Program Duration Rules Form (SFACPLR). The corrected program lengths apply to all students with catalog terms beginning Fall 2025 and forward. Per system guidance, existing students will retain the prior six-year duration to prevent retroactive enrollment reporting errors in the Clearinghouse. This corrective action permanently resolves the program length discrepancy for future reporting and ensures compliance with GE/FVT and NSLDS requirements. Anticipated Completion Date: August 14, 2025 Western Connecticut State University Contact Person: Debra Zavatkay, Ed. D., Registrar (203) 837-8229
Finding No. 2025-002 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The registrar will complete a 100% audit of the withdrawals for Fall 2025 and Spring 2026 to verify that the dates the students were withdrawn in t...
Finding No. 2025-002 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The registrar will complete a 100% audit of the withdrawals for Fall 2025 and Spring 2026 to verify that the dates the students were withdrawn in the Student Information System matches the dates the students signed the Total Withdrawal or Add/Drop forms. Anticipated Completion Date: The audit should be completed by the end of June 2026. Starting the Summer 2026 semester, the withdrawal dates in Sonis and the dates the students sign the Total Withdrawal or Add/Drop forms will be verified on a weekly basis. Person(s) Responsible for Corrective Action: Evelyn M. Bryant Assistant Vice President of Registrar Services 910-257-3452
Finding No. 2025-001 – Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The discrepancies identified during the current audit were determined to be timing-related issues associated with the transition and implementation of revised disbursement reporting an...
Finding No. 2025-001 – Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The discrepancies identified during the current audit were determined to be timing-related issues associated with the transition and implementation of revised disbursement reporting and reconciliation procedures in order to address a similar compliance finding that was identified in the 2024 Single Audit. These discrepancies occurred while updated controls and monitoring processes were being fully integrated into daily operations. During the prior audit conducted on April 6, 2025, auditors identified discrepancies between institutional disbursement dates and the dates reflected in the Common Origination and Disbursement (COD) system for the 2023-2024 award year. Immediately upon identification of the issue in the 2024 Single Audit, the institution implemented corrective measures to ensure that institutional disbursement dates matched Common Origination and Disbursement (COD) reporting. Since May 2025, the following corrective actions have already been fully implemented: 1. Revised and strengthened reconciliation procedures between the Student Information System and COD to ensure accurate disbursement date reporting. 2. Implemented secondary review controls prior to transmitting disbursement records to COD. 3. Established ongoing internal monitoring and periodic reconciliation reviews to identify and resolve discrepancies promptly. 4. Conducted additional staff training regarding Title IV disbursement reporting requirements and COD reconciliation procedures. 5. Assigned designated personnel responsibility for continuous oversight and verification of disbursement date accuracy. 6. Corrected disbursement reporting processes to ensure institutional records align with COD reporting requirements moving forward. Anticipated Completion Date: Since May 2025, the institution has taken all necessary measures to address and correct the identified issues on a prospective basis. All corrective actions outlined above are currently in place and operational. The institution continues to monitor disbursement reporting and reconciliation processes to ensure ongoing compliance with federal Title IV regulations and accurate reporting to COD. Person(s) Responsible for Corrective Action: Beatriz Novoa-Cruz Associate Vice President of Enrollment 718-429-6600 ext. 114
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend Hazelden Betty Ford Graduate School review their policies and procedures relating to return of Title IV calculations to ensure the calculations are properly set up to round. Explanation of disagreement ...
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend Hazelden Betty Ford Graduate School review their policies and procedures relating to return of Title IV calculations to ensure the calculations are properly set up to round. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Rounding rules have been applied to the Return of Title IV calculation worksheets according to the federal Title IV regulations. 2) Discrepancies in R2T4 calculations due to the rounding issue have been corrected on COD on a student by student basis Name(s) of the contact person(s) responsible for corrective action: Yuan Fang Planned completion date for corrective action plan: April 1, 2026
RE: Funding 2025-001 – Incorrect student status, Corrective Action Plan To whom it may concern: Student Financial Assistance Cluster (ALNs: 84.063 and 84.268) Management concurs with the findings. Management acknowledges that the condition identified is primarily attributable to staff turnover assoc...
RE: Funding 2025-001 – Incorrect student status, Corrective Action Plan To whom it may concern: Student Financial Assistance Cluster (ALNs: 84.063 and 84.268) Management concurs with the findings. Management acknowledges that the condition identified is primarily attributable to staff turnover associated with the closure of the school, which resulted in disruptions to established processes and reduced the effectiveness of controls over the determination and documentation of student eligibility. Management has ensured the appropriate reporting has now been made to the NSLDS. The SFA program has been terminated and therefore will not impact future audits. Leadership Responsible: Colleen Walsh Dean, Student and Alumni Services Lawrence Memorial/Regis College (781) 979-3000 Anticipated Completion date: May 30, 2026
Management’s Response: Management understands the importance of ensuring information is reported accurately and timely and the requirement to report to the NSLDS the enrollment status of students who receive federal funds. The University will review its controls and procedures to ensure that not onl...
Management’s Response: Management understands the importance of ensuring information is reported accurately and timely and the requirement to report to the NSLDS the enrollment status of students who receive federal funds. The University will review its controls and procedures to ensure that not only are status changes reported to the Clearinghouse, but also that the enrollment changes are reported appropriately from the National Student Clearinghouse to NSLDS. Views of Responsible Officials and Corrective Action: We will reassess controls, review these processes and implement controls, including multiple layers of review, to ensure that timely and accurate enrollment reporting is made. Furthermore, the reporting data was appropriately updated subsequent to the required timeframe. Name of Responsible Person: LaShanda Chamberlain, Director of Student Financial Aid Implementation Date: Immediately
Management’s Response: Management understands the importance of ensuring Pell Grant amounts are properly calculated for each student. Management acknowledges and agrees with the findings as presented. Views of Responsible Officials and Corrective Action: We will implement controls, including reconci...
Management’s Response: Management understands the importance of ensuring Pell Grant amounts are properly calculated for each student. Management acknowledges and agrees with the findings as presented. Views of Responsible Officials and Corrective Action: We will implement controls, including reconciliation and multiple layers of review to ensure that accurate calculations are made. Name of Responsible Person: LaShanda Chamberlain, Director of Student Financial Aid Implementation Date: Immediately
Management’s Response: Management understands the requirements specific to calculating and returning unearned Title IV aid. Management acknowledges and agrees with the findings as presented. Views of Responsible Officials and Corrective Action: We will reassess controls, review these processes and i...
Management’s Response: Management understands the requirements specific to calculating and returning unearned Title IV aid. Management acknowledges and agrees with the findings as presented. Views of Responsible Officials and Corrective Action: We will reassess controls, review these processes and implement controls to ensure that timely calculations and return of funds are made. Furthermore, the funds noted were sent back prior to year-end. Name of Responsible Person: LaShanda Chamberlain, Director of Student Financial Aid Implementation Date: Immediately
Material Weakness in Internal Control over Compliance and Compliance - Allowable Costs Condition: During our testing of allowable costs, we identified IT-related expenses totaling $111,669 that were charged to the major program for services that were not performed by the vendor and for which the ent...
Material Weakness in Internal Control over Compliance and Compliance - Allowable Costs Condition: During our testing of allowable costs, we identified IT-related expenses totaling $111,669 that were charged to the major program for services that were not performed by the vendor and for which the entity did not receive any benefit. These costs were subsequently reimbursed to Concilio by the funder. Recommendation: We recommend that management strengthen internal controls over vendor payments and grant billings to ensure that only costs for services actually rendered and properly supported are charged to federal awards. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has initiated corrective actions to strengthen internal controls over vendor payments, procurement, and grant billing processes. Upon discovery of the issue, management reviewed the affected transactions and ensured reimbursement of the questioned costs to the funding agency. Procedures have been enhanced to require appropriate documentation and supervisory approval confirming that services are properly rendered prior to payment and charging of costs against awards. In addition, management has strengthened vendor oversight and contract monitoring processes, including improved verification of invoices against contractual deliverables and supporting documentation. The Compliance functions have been enhanced to include periodic reviews of program expenditures, and additional staff training will be provided on allowable cost requirements, compliance standards, and documentation expectations to prevent recurrence of similar issues. Name of the contact person responsible for corrective action: Asif Mehmood, Chief Financial Officer asif.mehmood@elconcilio.net (215)627-3100 Planned completion date for the corrective action plan: June 30, 2026
Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 60 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services...
Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 60 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 43 CUA Safety Assessments, (b) 38 CUA Safety Plans, (c) 15 CUA PA Model Risk Assessments, (d) 8 CUA Documented Client Visits (Structure Case Notes), (e) 21 FAST Family Advocacy Forms, (f) 21 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 15 School Aged Report Cards, (h) 23 CUA Authorization to Release Information, (i) 12 CUA Immunizations, (j) 22 DHS Court Order Sheets, (k) 11 Child’s Photo, (l) 9 Initial CUA Single Case Plan, (m) 11 6-Month Updates to CUA Single Case Plan, (n) 2 Initial CUA Case Service Conference Summary Report, and (o) 2 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 23 DHS Service Authorization Forms, (b) 25 DHS CUA Provider Referral Forms, and (c) 20 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Enhancement of the Quality Assurance Department to strengthen oversight, monitoring activities, and internal review processes across programmatic and administrative functions. 3. Implementation of monthly reviews of client files and supporting documentation to ensure accuracy, completeness, and compliance with contractual and funding requirements. 4. Provision of enhanced staff training focused on the review of audit findings, identification of control deficiencies, and timely implementation of corrective actions. Name of the contact person responsible for corrective action: Asif Mehmood, Chief Financial Officer asif.mehmood@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2026
Management acknowledges the finding related to student eligibility and internal controls over Direct Loan aggregate limits and agrees that enhancements are necessary to ensure full compliance with federal requirements.
Management acknowledges the finding related to student eligibility and internal controls over Direct Loan aggregate limits and agrees that enhancements are necessary to ensure full compliance with federal requirements.
This condition relates to the prior fiscal year and occurred before centralized oversight of Financial Aid operations was established under the Business Services division in February 2026.
This condition relates to the prior fiscal year and occurred before centralized oversight of Financial Aid operations was established under the Business Services division in February 2026.
Corrective actions implemented and in progress include:
Corrective actions implemented and in progress include:
· Implementation of a formal pre-disbursement review process to verify aggregate loan limits using NSLDS data
· Implementation of a formal pre-disbursement review process to verify aggregate loan limits using NSLDS data
· Strengthening system validation procedures to ensure integrations and automated controls are functioning as intended
· Strengthening system validation procedures to ensure integrations and automated controls are functioning as intended
· Establishment of supervisory review for students approaching aggregate loan limits and higher-risk disbursements
· Establishment of supervisory review for students approaching aggregate loan limits and higher-risk disbursements
· Review and correction of identified overawards, with coordination for any required adjustments or repayments
· Review and correction of identified overawards, with coordination for any required adjustments or repayments
· Enhanced staff training on federal eligibility requirements and monitoring procedures
· Enhanced staff training on federal eligibility requirements and monitoring procedures
· Ongoing monitoring and periodic internal review to ensure continued compliance
· Ongoing monitoring and periodic internal review to ensure continued compliance
Management is committed to strengthening internal controls over Title IV programs and ensuring sustained compliance with federal regulations.
Management is committed to strengthening internal controls over Title IV programs and ensuring sustained compliance with federal regulations.
Board resolutions be approved identifying employees and salary amounts to be charged to the Title IV grant cluster. In addition, time and effort supporting timesheets be made available for hourly employees charged to the grant.
Board resolutions be approved identifying employees and salary amounts to be charged to the Title IV grant cluster. In addition, time and effort supporting timesheets be made available for hourly employees charged to the grant.
Corrective Action Plan: NSLDS Reporting Institution: Congregation YMH d/b/a Yeshiva Meor Hatalmud Audit Period: Year Ended August 31, 2025 Finding 2025:001: Noncompliance with NSLDS Enrollment Reporting Requirements Views of Responsible Officials The Organization acknowledges a misunderstanding duri...
Corrective Action Plan: NSLDS Reporting Institution: Congregation YMH d/b/a Yeshiva Meor Hatalmud Audit Period: Year Ended August 31, 2025 Finding 2025:001: Noncompliance with NSLDS Enrollment Reporting Requirements Views of Responsible Officials The Organization acknowledges a misunderstanding during the initial year of the program regarding the necessity of NSLDS reporting when student loans are not present. Upon clarification, management prioritized resolving this reporting requirement. Corrective Action Taken • System Registration: The institution successfully finalized its registration with the National Student Loan Data System (NSLDS). • Technical Resolution: Initial attempts to resolve technical access issues began on March 30, 2026. These issues, tracked under Case #260330-000528, were fully resolved on April 29, 2026. • Reporting Compliance: The Organization completed its initial enrollment reporting at both the Campus and Program levels to the Department of Education on April 29, 2026. • Verification of Proof: Official confirmation of the successful registration and enrollment reporting has been provided to auditors. • Internal Controls: To ensure ongoing compliance with 2 CFR §200.303(a), the Organization established formal procedures. These include monthly monitoring of enrollment changes, maintaining an audit trail of NSLDS communications, and assigning specific reporting responsibilities to the administrative office. Completion Status: Resolved/ Completed Responsible Person: Mr. Frisch, Administrator
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2025 Finding 2025-002 - Untimely Reporting of Disbursement Records Grantor: Program: Assistance Listing #: Award Titles: Award Years: U.S. Department of Education Student Financial Assistance Cluster 84.268, 84.063 Federal...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2025 Finding 2025-002 - Untimely Reporting of Disbursement Records Grantor: Program: Assistance Listing #: Award Titles: Award Years: U.S. Department of Education Student Financial Assistance Cluster 84.268, 84.063 Federal Direct Student Loan Program, Federal Pell Grant Program 7/2024 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Management has established controls to facilitate the timely reporting of all federal aid disbursements. Additional staff have undergone cross-training to perform disbursement originations in the event that the Financial Aid Senior Manager is unable to perform the control, with management providing ongoing oversight to ensure consistent compliance. Timing: The process mentioned above was implemented on 4/25/2026 Signed and Acknowledged Makoa Freitas Finance Director / Controller
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2025 Finding 2025-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System Grantor: Program: Assistance Listing #: Award Titles: Award Years: U.S. Department of Educ...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2025 Finding 2025-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System Grantor: Program: Assistance Listing #: Award Titles: Award Years: U.S. Department of Education Student Financial Assistance Cluster 84.268, 84.063 Federal Direct Student Loan Program, Federal Pell Grant Program 7/2024 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Consistent with prior year's corrective action plan, on May 31, 2025, management implemented a new review process to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse and National Student Loan Data System. Since the successful implementation of the corrective action plan, there have been no instances of non-compliance identified. Timing: The corrective action plan was implemented on May 31, 2025. Signed and Acknowledged Makoa Freitas Finance Director / Controller
Finding 2025-001 – Untimely Reporting of Disbursement Records Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.063 Award Titles: Federal Pell Grant Program Award Years: 7/2024 – 6/2026 Management agrees with the finding and proposes the foll...
Finding 2025-001 – Untimely Reporting of Disbursement Records Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing#: 84.063 Award Titles: Federal Pell Grant Program Award Years: 7/2024 – 6/2026 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan In order to maintain timely disbursement reporting, senior financial aid staff will be cross-trained by the Financial Aid Manager/Director to perform disbursement originations as a back-up in the event that the Financial Aid Manager/Director is unable to perform the control. Additionally, in order to prevent human error in reporting, financial aid procedures will be updated to include a reconciliation between PeopleSoft and COD every 7–10 days to ensure that all disbursement originations are accurate and that any discrepancies are identified and corrected in a timely manner. Timing In February 2025, the Senior Financial Aid Specialist was cross-trained by the Financial Aid Manager to perform disbursement originations when the primary control owner is unable to complete this control. Going forward, additional training will be provided by the Financial Aid Director as needed to the appropriate financial aid personnel. The new procedure to reconcile between PeopleSoft and COD every 7–10 days was implemented in October 2025. With these changes, there are now three employees trained to reconcile and perform disbursement originations to ensure the timeliness of disbursement reporting.
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