Corrective Action Plans

Finding: Allowable Activities & Allowable Costs and Eligibility (Reference Number: 2024-001) Criteria or Specific Requirement: Funds may be expended for foster care maintenance payments on behalf of eligible children, in accordance with the Title IV-E agency’s foster care maintenance payment rate schedule and in accordance with 45 CFR section 1356.21, to individuals serving as foster family homes, to childcare institutions, or public/private child-placement or child-care agencies. In accordance with Code of Colorado Regulations (CCR) section 7.302.2, for each child, Jefferson County Human Services (JCHS) must have an agreement with the provider which details the daily maintenance payments. JCHS agreement to purchase services must be signed by the provider and JCHS. Additionally, in accordance with CCR section 7.301.3, the Family Services Plan shall be reviewed in conference with the caseworker and supervisor every 90 calendar days. Condition: • Two instances out of 40 where there was no signed agreement in place to support revised maintenance payments following a child’s 9th birthday. The correct maintenance amount was paid to the provider in accordance with the State of Colorado rates published in IM-CW–2024-0028 and IM-CW-2023-0021. • One instance out of 40 where the required 90-day review was not completed on time. The review was conducted 15 days late. Cause: The state's Foster Care system did not automatically generate a notice that a new agreement to purchase services was needed based on the child's birthday. Additionally, JCHS lacks an effective control mechanism to proactively identify when a 90-day review is approaching or overdue. Corrective Action Plan: We agree with the finding. The Integrated Case Management System (ICM) is designed to generate an email notification to Collaborative Foster Care Program (CFCP) staff when a child turns 9 or 14 years of age while in foster care. This email notification instructs CFCP staff to generate a new Child Specific Addendum (SS23-B) due to the increase of the child maintenance rate. This email instructs and standard procedure requires CFCP staff to verify the child maintenance rate in Trails after an SS23-B is generated. The IT Systems Support Team responsible for the maintenance of ICM determined that ICM has failed to notify CFCP staff when a child turned 9 or 14 years of age while in foster care: • The IT Systems Support Team responsible for the maintenance of ICM has been asked to ensure that ICM is generating an email notification when a child turns 9 or 14 years of age while in foster care. • While this issue is being addressed in ICM, the CFCP requested a report that included the birthdays for all children in foster care. CFCP staff have generated new Child Specific Addendums (SS23-B) for children that have turned 9 or 14 years old while in foster care. CFCP staff will utilize this report to generate new Child Specific Addendums for future birthdays. • After a new Child Specific Addendum is generated, staff will verify the child maintenance rate in Trails. • The CFCP has determined that it can no longer rely on ICM and has decided to migrate its functionality over to the ancillary system supported by Jefferson County known as the Caseworker Application Timesaver (CAT). With this migration, the email notifications will resume so that CFCP staff are properly notified of the need to generate the new SS23-B and verify the child maintenance rate. • Migration is scheduled to occur on Friday, June 20, 2025. • On Monday, June 23, 2025, the CFCP will meet with the Jefferson County Application Program Analyst to ensure the migration was successful. • Additionally, the CFCP and the Jefferson County Application Program Analyst have scheduled a second meeting for July 9, 2025, to ensure the successful migration from ICM to CAT. • To ensure 90-Day Reviews are completed timely, the Division of Children, Youth, Families, and Adult Protection (CYFAP) will continue to utilize the 90-Day Review compliance feature of CAT. Additionally, CYFAP leadership will emphasize this requirement with supervisors and casework staff and ensure their compliance. Person(s) Responsible for Implementation: Barb Weinstein, Director, Division of Children, Youth, Families and Adult Protection Implementation Date: July 1, 2025

2024-003 – Cash Management (Significant Deficiency) Department of Education, SFA Cluster, Cash Management Criteria: In accordance with 34 CFR 668.164, an institution submits a drawdown request for funds utilizing ED’s electronic grants management system that may not exceed the amount of funds needed to make immediate disbursements to eligible students and parents. The institution must disburse the requested funds as soon as administratively possible, but no later than three business days following receipt of those funds from ED. Any funds not disbursed by the end of the third business day are considered excess cash. Condition: A sample of twenty-six students were tested for timely distribution of federal student aid funds. Aid was distributed more than three business days after funds were received from ED for all students tested. Cause: Lack of controls over cash management. Effect: Excess federal cash retained by the institution. Recommendation: We recommend the University implement appropriate training regarding compliance regulations into the employee onboarding process and thereafter for applicable employees. In addition, we recommend the University implements timely review procedures to ensure that any overdrawn funds are returned within the tolerance period. Action Taken: The University acknowledges the deficiency in the timely disbursement of Title IV funds and has taken immediate corrective action to strengthen cash management controls. Specifically, the Financial Aid Office and the Business Office collaborated to revise internal procedures to ensure that federal funds are disbursed within three business days of receipt from the U.S. Department of Education. Effective 7/16/2025, a new standard operating procedure (SOP) was implemented, which includes: 1) Weekly reconciliation between Campus Anyware and G5 drawdowns to track the timing of funds received and disbursed. 2) Mandatory compliance training on federal cash management regulations for all financial aid and student accounts staff, both during onboarding and annually thereafter. 3) Monthly internal audits to review disbursement timelines and identify exceptions. Additionally, any funds inadvertently held beyond the three-day window are now promptly returned to G5 within the regulatory tolerance period. Responsible Party and contact information: Triniti Lee – Financial Aid Processor, Leetk2@webber.edu, Adhley Neal – Business Office Processor, nealad@webber.edu. Expected Date of Correction: 8/1/2025

2024-005 – Over Award of Federal Pell Grant Program Funds (Significant Deficiency) Department of Education, SFA Cluster, Special Tests and Provisions Criteria: In accordance with 34 CFR 668.32, a student is eligible to receive Title IV, HEA program assistance if the student meets all of the requirements in 34 CFR 668.32 paragraphs (a) through (m). 34 CFR 668.32(a)(1)(i) requires the student to be a regular student enrolled, or accepted for enrollment, in an eligible program at an eligible institution. Condition: Of 26 students tested for eligibility, one student received Title IV, HEA program assistance for a semester that the student was not enrolled in. Cause: Controls are not functioning properly. Effect: Title IV program funds were awarded to a student who was not eligible to receive such funds. Recommendation: We recommend the University review and update its procedures to ensure that Title IV funds are awarded properly. Management Response: The University acknowledges the over-award of Title IV funds due to disbursement for a student who was not enrolled during the term in question. In response, the University has strengthened its internal controls to ensure that federal aid is awarded and disbursed only to students who meet all eligibility criteria as outlined in 34 CFR 668.32. Corrective actions taken include: 1) System Validation Enhancements: The student information system has been updated to include enhanced enrollment validation checks before the release of Title IV funds. Title IV disbursements are now restricted to students with confirmed active enrollment in eligible programs for the applicable term. This is enforced through automated disbursement blocks that are triggered when enrollment data is missing or inconsistent. 2) Pre-Disbursement Review Process: A pre-disbursement verification step has been implemented, requiring financial aid staff to confirm active enrollment statuses before releasing funds. 3) Staff Training: Targeted training has been provided to financial aid staff on Title IV enrollment eligibility requirements. Responsible Party and contact information: Triniti Lee – Financial Aid Processor, Leetk2@webber.edu. Expected Date of Correction: 8/1/2025

2024-004 –Satisfactory Academic Progress Policy (Significant Deficiency) Department of Education, SFA Cluster, Eligibility Criteria: In accordance with 34 CFR 668.34(a), an institution must establish a reasonable satisfactory academic progress policy for determining whether an otherwise eligible student is making satisfactory academic progress in his or her educational program and may receive assistance under Title IV, HEA programs. A student placed on academic probation may receive Title IV, HEA program funds for one payment period. At the end of one payment period on financial aid probation, the student must meet the institution's satisfactory academic progress standards or meet the requirements of the academic plan developed by the institution and the student to qualify for further Title IV, HEA program funds. Condition: Our review of 26 student files disclosed that one student was placed on academic probation after fall 2023 semester and received Pell for spring 2024 semester. The student did not meet satisfactory academic progress standards at the end of spring 2024 semester, however, the student received Pell for summer semester 2024. Cause: Controls are not functioning properly. Effect: Title IV program funds were awarded to a student who was not eligible to receive such funds. Recommendation: We recommend the University review and update its policies to ensure that the University’s Satisfactory Academic Progress policy is enforced. Management Response: The University acknowledges the oversight in the enforcement of its Satisfactory Academic Progress (SAP) policy and has taken corrective action to address the deficiency. Specifically, the Financial Aid Office has conducted a comprehensive review of SAP monitoring procedures to ensure full compliance with federal regulations under 34 CFR 668.34. Corrective steps taken include: 1) Policy Clarification and Staff Training: The SAP policy has been reviewed and clarified to emphasize the requirement that a student failing to meet SAP after one payment period on financial aid probation is no longer eligible for Title IV funds unless they meet the conditions of an approved academic plan. Targeted training was delivered to financial aid counselors and compliance staff to reinforce correct application of SAP policies and documentation protocols. 2) Automated SAP Compliance Flag: An automated flag has been integrated into the student information system to alert staff when a student has reached the end of a probation period. This flag prevents Title IV disbursement until a manual review confirms eligibility based on SAP or academic plan compliance. 3)Ongoing Monitoring and Quality Assurance: At the conclusion of each academic term, the University runs comprehensive SAP reports to identify all students who have either regained eligibility, remained on SAP, or have newly been placed on SAP status. The student information system is configured to automatically flag these students and restrict Title IV disbursements through system-based controls in the auto-packaging process, thereby preventing ineligible aid disbursements and ensuring compliance with federal regulations. Responsible Party and contact information: Pamela Denton - Financial Aid Counselor, dentonpe@webber.edu, Trinity Lee – Financial Aid Processor, Leetk2@webber.edu. Expected Date of Correction: 8/1/2025

Identification: 10.766 United States Department of Agriculture (USDA), Community Facilities Loans and Grants Cluster, Noncompliance Finding/Significant Deficiency, Special Tests and Provisions. Corrective Action Plan: The Medical Center will seek guidance from the bond trustee and USDA related to the insurance provisions in the bond documents for the amount of fidelity bond coverage and retaining an insurance consultant to provide a report. Anticipated completion date: The Medical Center anticipates this to be completed during 2025.

Identification: 10.766 United States Department of Agriculture (USDA), Community Facilities Loans and Grants; Noncompliance Finding; Special Tests and Provisions Corrective Action Plan: The Medical Center will take the necessary steps outlined in the bond indenture and work with the bond trustee in order to improve the financial covenants and come back into compliance. Anticipated completion date: The Medical Center anticipates this to be completed during 2025.

Title IV-E Foster Care Assistance Listing No. 93.658 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Preparer of drawdown request will have approval from another finance team member. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: Complete and ongoing

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ...... Jennifer Scott-Gilmore 601-857-3250 The District did not properly calculate the total amount disbursed or to be disbursed which lead to incorrect calculation of funds to be returned to Title IV. Additionally, the District did not provide evidence of date of determination used in calculation. b. Corrective Action Plan: The District is an attendance taking institutional and has reviewed its internal controls on how total days in the semester are calculated correctly and timely disbursements are made. The District understands that it should be using the Last Day of Attendance in the calculation of earned aid and made that modification Spring 2025 in collaboration with the U.S. Department of Education and outlined the calculation variables to align with that calculation change. Management has revised its Policy and Procedures accordingly and will submit to the Hinds Board of Trustees for final approval December of 2025. The correction implementation date was June 2025 to be finalized December 2025.

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services .... Jennifer Scott-Gilmore 601-857-3250 The District did not report timely and accurate student status information to the National Student Loan Data System (NSLDS). The District did not ensure internal controls were in place to ensure timely and accurate reporting. b. Corrective Action Planned: The Management has implemented additional organizational and internal controls to ensure students' enrollment statuses are reported timely and accurately. In reviewing the causation of the finding, it was determined that it was a personnel error and as of June 2024, there is a new Registrar for Hinds Community College charged with compliance of this requirement. During the AY2024-25, the Registrar worked within the new student information system (SIS) to generate the required student data on a monthly cycle to be submitted to the National Clearinghouse which is then transmitted to NSLDS. This update in internal controls should satisfy future reviews.

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ...... Jennifer Scott-Gilmore 601-857-3250 The District using a Servicer to Deliver Title IV Credit Balances to a card did not provide a URL for the contract to the Department of Education in the Cash Management Contracts Database and disclose the contract on the District's website. b. Corrective Action Planned: The Management has reviewed the District process of delivering Title IV credit balances to students. Management will disclose the third-party contractual agreement to its Servicer as well and provide the URL to the Department of Education via the Cash Management Contracts Database. The anticipated completion date is August 2025.

2024-005 TIMELINESS OF FEDERAL REPORTING County personnel responsible for resolution: Timothy Rutkowski, Prosecuting Attorney Ann Schultz, Friend of the Court/Director of Juvenile Services Corrective action plan response: The County will review current procedures and implement new procedures as necessary to ensure all reports are completed, reviewed, and submitted timely. Anticipated completion date: December 31, 2025

The late audit submission was a result of significant leadership and staffing turnover, unresolved audit support items, and missing reconciliations from prior months. The University engaged an external firm to stabilize the finance function and has since appointed an interim Controller. Beginning with FY26, the University will adopt a rolling monthly close schedule, establish an internal audit prep calendar, and define internal deadlines for deliverables to external auditors. These steps will support timely completion of future audits. Target: Audit submission by March 31, 2026 for FY25.

The University concurs with this finding. Due to turnover in critical roles, the FY24 FISAP contained inaccuracies. The University has appointed an interim Controller to oversee the correction of reporting processes. The new process will require that all FISAP data be supported by reconciled financial records and reviewed collaboratively by Financial Aid and Accounting staff. Process updates and internal review checklists will be developed in time for the FY25 submission, with training and testing of the new approach by June 30, 2026.

This finding resulted from a loan disbursement exceeding regulatory limits for one student. The issue was corrected before the audit report was finalized. The University will strengthen its review process prior to disbursement by ensuring additional loan eligibility is validated and documented. The Financial Aid Office will receive targeted training on aggregate loan monitoring. Corrective actions will be fully implemented by January 31, 2026.

The University acknowledges the enrollment status reporting errors noted in the audit. This was due to a lack of coordination between departments responsible for enrollment status updates and NSLDS reporting. Under the direction of the interim Controller, the University will work with Registrar, Office of Records and Registrations to implement a monthly reconciliation process and establish clear ownership of status reporting responsibilities. A tracking log will be introduced to monitor timely and accurate submissions. Completion of corrective actions is expected by March 31, 2026.

As of today’s date, the institution has forwarded the corrections to Financial Aid Services to be made in NSLDS. The institution will verify the corrections have been completed by June 20, 2025. In addition to the corrections the institution has and will continue training to better understand the dates to be reported in NSLDS when there is a student on a Leave of Absence that does not return.

The Child and Family Services Agency (CFSA) concurs with this finding as stated. The corrective action is already completed. Formal correspondence protocols are in place as of April 1, 2025. Contact: James Murphy, Business Services Administrator Estimated Completion Date: Completed See Corrective Action Plan for chart/table

The Child and Family Services Agency (CFSA) concurs with the findings. The finding involved a recurring formula error in the workbook CFSA uses to calculate its lapsing quarter family-based rate adjustment. The issue stemmed from the pandemic-era stimulus funding that increased the District’s FMAP percentage from the standard 70% to 76.2%, which CFSA accommodated in its family-based rate adjustment claiming tools with manual entries. Corrective action is outlined below, but in the meantime the District has returned to the standard 70% FMAP, which precludes recurrence. To address Condition 1 going forward, expenditures occurring within the current fiscal year will be reflected on the SEFA for the Foster Care grant and be consistent with claimed expenditures reported on the CB 496. The CFSA Agency Fiscal Officer and the CFSA Accounting Supervisor will develop a written procedure to prevent expenditures from being charged to other periods. The principal corrective action for Condition 2 will be to update the entire suite of financial tools that undergird the family-based rate adjustment claims. The updates will feature formula “fail safes” that will require validation of the various statistics that inform the claims. CFSA will make an adjusting entry for the entirety of the questioned costs in the next federal claim, to be submitted on or before August 15, 2025. Contact: James Murphy, Business Services Administrator Estimated Completion Date: September 30, 2025 See Corrective Action Plan for chart/table

The Child and Family Services Agency (CFSA) concurs with the findings. The licensure issue involved a provider who was in process of permanently closing her home as a foster care provider (and the existing license expired in the meantime), and the other item involved a brief lapse in the child protection register check. Corrective action will involve improved automation within the claiming process. CFSA also acknowledges that the third bullet regarding the legibility of the background criminal check document for the “other adult in the home” is an internal control issue for which there are no questioned costs. Corrective action will occur within STAAND implementation as key system edits in the foster care maintenance claim report will account for lapsing/expiring (according to District standards) licensure documentation. Payments to providers that do not meet title IV-E requirements across all axes will be left out of the IV-E foster care maintenance claim. Contact: James Murphy, Business Services Administrator Estimated Completion Date: December 31, 2025 See Corrective Action Plan for chart/table

The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Action plan steps include the following: • The Office of the Registrar will continue to use National Student Clearinghouse third party reporting tool to report enrollment data to NSLDS. • The Office of the Registrar continue to utilize the "Submission schedule tool" to keep us compliant with the timeframe required for submission of the reports. • Students who have been reported during the first week of courses as "Never Attended - NA" will be dropped from there courses for the term no more than 1 week after the end of attendance verification. • The Enrollment Time Status (Full Time, Part Time, etc.) for student who are enrolled in Summer courses will be updated effective immediately. Contact: Nakia Pugh, Associate Registrar Estimated Completion Date: June 2, 2025 See Corrective Action Plan for chart/table

The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Action plan steps include the following: • Correcting the Issue - R2T4 Funds have been returned in COD as of 06/03/25 for sample selection #15 of the R2T4 sample. • Reporting the Downward Adjustment to update COD - R2T4 Funds have been returned in COD as of 06/03/25 for sample selection #15. • Review all official and unofficial R2T4s - We will now pivot to ensure that all R2T4 files are reviewed as opposed to only a random selection. Also, we will now begin to send email notifications to both loan and Pell reporting individuals. Additionally, calendars for all involved staff members will be updated to reflect the regulatory requirements for returning Title IV funds. Wayne Montgomery, Director of Financial Aid Contact: Katrina Johnson, Compliance Officer Estimated Completion Date: June 3, 2025 See Corrective Action Plan for chart/table

The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Action plan steps include the following: • The Bursar or designee shall run a report daily of all Title IV disbursements that occurred on the prior business day. • The Bursar or designee will run the SA Registration Review report for the terms shown on the disbursement report above and select students who had a Title IV disbursement based upon the report above. • The students with the disbursements shall be reviewed in addition to any other student shown having a Title IV Credit balance to determine if a non-refunded Title IV credit balance exist. • Where a non-refunded Title IV credit balance exist, the student shall be included in the list of refunds named Refund Review Report dd/mm/yyyy to be processed following the institution refund process for Title IV Credit Balances. • At the end of the day, the Bursar or designee shall generate a report showing the refunds entered in the SIS for that day and confirm all previously identified Title IV refunds credit balance refunds were completed and attach said report to the refund review report and save in a designated folder. • The Bursar or designee will complete the batch release process daily to allow refund entered on student records to be transmitted to AP following institutional process. • On the AP check run date, the Bursar or designee shall review the check run notification from AP to confirm all refunds entered in SIS since last check run date have been processed successfully. Contact: Stephen Toppin, Bursar Estimated Completion Date: June 8, 2025 See Corrective Action Plan for chart/table

Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the birth certificate was identified and the youth was determined to be Title IV-E eligible. MDHHS will reclassify the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement. For those cases in which Title IV-E funding is denied initially based on lack of a birth certificate or other documentation of citizenship, the Child Welfare Funding Specialists will continue to monitor the case for updated documentation in order to complete a redetermination of funding. Child Welfare Funding Specialists will be reminded to monitor cases for updated documentation during a Child Welfare Funding conference call in June 2025. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Nancy Berger, MDHHS

The instances identified in this finding represent individuals who, in several cases, were processed in the same batches ( e.g., COD date 9/28/23, disbursement date on ledger 10/3/23, and COD date 11/3/23, disbursement date 11/8/23). CMN recognizes the importance of disbursing funds to student accounts on the date that funds are stated to be disbursed through COD. While there have been instances of funds not being available in COD in a timely manner, the financial aid coordinator and bursar will work together to ensure these disbursements are completed on the same date in order to remain compliant with stated CMN policy.

The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for all three students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Student 1: After changing from an attendance-taking institution to a non-attendance taking institution, this student was identified during the audit as a student who may not have completed the term due to all F/NP grades. Calculation was completed and a return was made based on the midpoint date of the spring term. Student 2: After changing from an attendance-taking institution to a non-attendance taking institution, this student was identified during the audit as a student who may not have completed the term due to all F /NP grades. Calculation was completed and a return was made based on the midpoint date of the spring term. Student 3: Student officially withdrew but withdrawal was not processed until the end of the term. Since the withdrawal was not processed in a timely manner, the enrollment status (as noted in fmding 2024-001) and subsequent R2T4 calculation was delayed. Calculation was completed and a return was made based on the date indicated in the official withdrawal documents. Due to delayed calculations on these three students, CMN will continue to work with fmancial aid staff and the registrar's office to streamline communication on withdrawals and students who complete the term with all F/NP grades, as indicated in CMN policy. CMN has already worked with Anthology (student information system)'to provide electronic triggers to the fmancial aid office when a student status changes from active to drop/withdrawal. Additionally, Enrollment Management notifies all faculty by email at the beginning of the term and again prior to fmal grades being submitted that electronic notification must be sent by the faculty to financial aid in order to alert the fmancial aid office of the date oflast academic engagement for students who earn an For NP grade. For the current audit period, the Director of Enrollment Management and the Financial Aid Coordinator work together to review a final grade report for all students and identify those who need R2T4 calculations based on that review. Both the director and coordinator sign the working documents to indicate that it has been reviewed by both parties. We will continue with this process and will refme as necessary, but we anticipate that this will resolve the issue of calculations not having been performed on students with all F /NP grades at the end of the term.