Corrective Action Plans

2023-006 - Student Financial Aid Cluster - (a) Federal Supplemental Educational Opportunity Grants (b) Federal Work Study Program (c) Federal Pell Grant Program (d) Federal Direct Student Loans, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.063 (d) 84.268 - Year Ended June 30, 2023 Condition: During our testing of twenty individuals receiving federal work study, we noted one individual (5%) was paid an incorrect pay rate for federal work study hours worked. We consider this condition to be an instance of noncompliance relating to the Activities Allowed or Unallowed compliance requirement and is not a repeat finding. Statistical sampling was not used in making sample selections. Corrective Action Plan: When rates of pay change, and Employee Authorization document is submitted through a series of individuals (Director of Financial Aid, Supervisor, VP, VP of Financial Services, Human Resources & the President) and signed/approved. This document is then received by the Payroll Coordinator. After payroll is completed, the VP of Financial Services thoroughly reviews all payroll items and verifies rate changes have occurred. Responsible Party for Corrective Action Plan: Payroll Coordinator & VP of Financial Services Implementation Date for Correction Action Plan: Implemented January 2023.

Condition Found: In accordance with the loan terms, Peabody Place is required to annually fund a capital asset replacement reserve of $100,000, debt payment reserve in the amount of $111,696, and a resident asset depletion reserve and facility fill reserve each for $50,000. The Organization did not make the required annual deposits into the debt payment reserve, capital asset replacement reserve, resident asset depletion reserve and the facility fill reserve. Individual(s) Responsible for Corrective Action: Lynda P. Goldthwaite, Executive Director and Stacey Matott, Director of Finance Planned Corrective Action: Peabody Place sought a debt work out in 2025 that would allow for deferral of required deposits for six months until January 1, 2026. Anticipated Completion Date: December 31, 2024

Benjie Read CFO and Felecia Read Staff Accountant, will update the policies and procedures for all program reports and the review of each before submission. We will also negotiate with the grantors for appropriate time frams as some of these time frames are impossible for us to meet in an accurate manner. These policies will be done within 90 days of audit completion.

2023-004 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s December 31, 2022 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Views of Responsible Officials and Planned Corrective Actions: The County is working with its fee accountant and external auditors to ensure a timely filing of the Single Audit going forward. Individual Responsible: Finance Department Timeline for corrective action: By December 31, 2026

Finding 2023-009 AL No.: 93.658 Program Title: Foster Care – Title IV-E Federal Agency: U.S. Department of Health and Human Services Pass-through Agencies: Wisconsin Department of Children and Families Award Number/Year 3413, 3561, 3681, 3645 / 2023 Condition/Context: There were 13 reports for submission for the County. Three reports were selected for testing. There was no documentation of a review control by someone independent of the preparer for all three reports tested. Our sample was not statistically valid. Management's Response: The finance department staff will work with departmental management and fiscal staff to review current documented and/or undocumented procedures, adopting and/or updating written procedures as necessary to ensure: • All assembled reports (typically prepared by fiscal staff) are reviewed for completeness and accuracy by independent personnel (typically a department head.) • Reports be submitted on a timely basis. • Reconciliation of data on each submitted reports to the financial statements. • Reconciliation of grant period-to-date cumulative data totals to the financial statements. Additionally, the county finance team will assemble and maintain a centralized file for all county grants, requiring grant administrators (fiscal staff or department heads) to report completion dates for mandated report filings. The county finance team will also maintain a centralized data file for all county grant filings and grant documents.

Finding 2023-009 – Completion and Submission of Annual Single Audit - Significant Deficiency/Noncompliance Condition/Context: The County's Single Audit and reporting package was delayed for the year-ended December 31, 2022, as a result of turnover within its Budget and Finance Office, beyond the nine month due date. Corrective Action: The Controller’s office has new procedures in place to help facilitate the year end closing process so the audit can be completed in a timely manner. Responsible for Implementing Corrective Action: Controller’s Office Anticipated Completion Date: We anticipate this to be completed in coordination with the 2026 audit.

Finding No.: 2023-008 Recommendation The College acknowledges the finding and is committed to addressing the gaps identified in enrollment reporting to the National Student Loan Data System (NSLDS). We recognize that accurate and timely reporting at both the Campus Level and Program Level is critical to maintaining compliance with U.S. Department of Education Title IV requirements and ensuring that students’ federal financial aid records are correctly reflected. Response 1. The College will retain the FAO as the lead unit responsible for NSLDS enrollment reporting, in alignment with Title IV compliance functions. However, the College will strengthen interdepartmental collaboration by establishing a formal partnership with the Registrar’s Office, which maintains the official record of enrollment data. 2. A shared workflow and communication protocol between the FAO and Registrar’s Office will be developed to ensure timely, accurate updates of both campus-level and program-level data. The Registrar’s Office will be responsible for updating student enrollment data, which serves as the source data for NSLDS reporting. The FAO will extract and upload these reports via the Enrollment Reporting Roster (ERR) on the NSLDS Professional Access portal. 3. The College will implement internal controls to track and verify changes in student enrollment status, program information, and key data elements. These controls will include but by no means limited to: a. A monthly reconciliation process between SIS data and NSLDS records. b. Use of exception reports to flag and resolve inconsistencies or delays. c. Documentation of all update logs for audit purposes. Periodic reviews will be conducted at least once per term to assess the accuracy and completeness of enrollment reporting. Any discrepancies will be promptly addressed and procedures updated as necessary to prevent recurrence. Relevant staff in both the FAO and Registrar’s Office will receive regular training on NSLDS reporting requirements, including proper use of record types (Campus vs. Program Level), enrollment status codes, and certification timelines. Training will emphasize the implications of noncompliance and best practices for accurate reporting. Training logs will be maintained by both the FAO and Registrar’s Office to support accountability and audit-readiness. Contact: VPEMSS Completion Date: September 30, 2025

Finding 2023-07 - Special Tests and Provisions: Disbursements to or on Behalf of Students Recommendation The College should implement a comprehensive communication strategy to ensure that all students receive clear and timely notifications regarding their Title IV funds. This should include the development of award letter of college financing plans that outline the amount and type of funds, as well as the disbursement schedule. Additionally, the College should establish a monitoring system to ensure that credit balances are disbursed within the required 14-day time frame to maintain compliance with federal records. Response The College acknowledges the finding and has initiated a process to address them. A formal request has been submitted to the SIS program developer for the implementation of a notification feature. The SIS vendor has confirmed development will be completed by July 1, 2025. This feature will ensure that students receive email notifications when they are awarded and reimbursed for any overpayments. Furthermore, we will establish an enhanced level of monitoring to ensure that credit balances are disbursed within the designated 14-day timeframe. Contact: Comptroller Completion Date: September 30, 2025

Finding 2023-06 – Special Tests and Provisions: Gramm-Leach-Bliley Act–Student Information Security Recommendation The College should develop and implement a comprehensive GLBA information security program that includes risk assessments, safeguards, and regular testing and monitoring of the effectiveness of these safeguards. A qualified individual with the necessary expertise and authority to oversee the GLBA information security program should also be designated. Provide training to relevant staff on GLBA requirements and the importance of information security. Conduct periodic reviews and updates of the information security program to ensure ongoing compliance with GLBA requirements. Response The college acknowledges the finding and will strengthen its student information security by implementing the following: 1) Designate a qualified Information Security Officer from within the IT Division or recruit externally if internal capacity is limited. 2) Develop a GLBA compliance program that includes: • Annual risk assessments • Implementation of administrative, technical, and physical safeguards • Staff training on data privacy • Annual testing of the security protocols Contact: Vice President for Institutional Effectiveness & Quality Assurance (VPIEQA) Completion Date: September 30, 2025

Finding No.: 2023-005 Recommendation The College should enhance training programs for staff involved in the verification process to ensure they are fully aware of the requirements and procedures. Establish robust internal controls and review mechanisms to ensure that verification worksheets are completed accurately and consistently with ISIRs. Implement a tracking system to ensure that all required corrections to ISIRs are performed in a timely manner. Response The College acknowledges the audit finding regarding verification errors, including the incorrect application of verification tracking groups, missing documentation, discrepancies between verification worksheets and ISIRs, and failure to make required corrections. In response, the Financial Aid Office (FAO) is committed to strengthening its verification procedures to ensure full compliance with federal regulations and to protect the integrity of Title IV funds. To this end, the College will implement the following corrective actions: 1. Policy and Procedure Enhancement a. The FAO will develop and implement a formal Standard Operating Procedure (SOP) for the verification process, revise and update all existing verification worksheet forms. This SOP will include: • Clear guidelines for identifying and applying the correct verification tracking groups (e.g., V1, V4, V5). • Procedures for resolving discrepancies between verification worksheets and ISIRs prior to award disbursement. • Steps for submitting timely and accurate ISIR corrections, as required. • A documentation checklist to ensure all required verification forms and statements of educational purpose are collected and properly stored. 2. Policy and Procedure Enhancement a. To ensure consistent understanding and application of federal verification rules, FAO staff across all campuses will: • Complete mandatory annual training sessions on verification policies, ISIR review, and regularly read updates on the Federal Student Aid (FSA) Knowledge Center. • Participate in internal refresher workshops focused on hands-on case processing and error prevention. • Complete relevant modules from the Federal Student Aid (FSA) training site, including those on verification tracking groups and identity verification requirements. 3. Verification Quality Control Protocol a. The FAO will implement a structured quality control protocol for verification, including: • A two-person verification review system in which one staff member processes the file and another independently reviews it for accuracy and completeness. • Use of a standardized review checklist to ensure all required documents match the ISIR and that any discrepancies are properly resolved and documented. • A log of all verification actions, including corrections submitted to FAFSA Processing System (FPS) and updates made in the student’s file, to support audit readiness. 4. Oversight and Accountability a. The Director of the Financial Aid Office (FAO) will be responsible for overseeing verification compliance and ensuring corrective actions are implemented effectively. This includes: • Monitoring the accuracy of verification tracking group assignments and documentation across all campuses. • Tracking the completion of required training for all FAO staff. • Conducting quarterly file audits to verify ongoing compliance with federal verification standards. • Reporting findings and corrective actions quarterly to the VPEMSS). Contact: VPEMSS Completion Date - September 30, 2025

Finding No.: 2023-004 Recommendation The College should establish a systematic process for reviewing and updating the origination records prior to submission to COD System. Response The College acknowledges the audit finding regarding the use of outdated cost of attendance (COA) figures and the uniform application of full-time enrollment status in COD origination records for the 2022–2023 academic year. In response, the Financial Aid Office (FAO) is committed to strengthening its policies and procedures to ensure accuracy, compliance, and proper stewardship of the Title IV funds. To this end, the College will implement the following corrective actions: 1. Policy and Procedure Enhancement a. The FAO will develop and implement a formal Standard Operating Procedure (SOP) for COD reporting. This SOP will include: • A COA validation checklist to ensure the correct, current year COA from the approved financial aid handbook is applied. • The college has continuously considered the applicants’ enrollment status (full-time, ¾-time, half-time, or less-than-half-time) when determining the cost of attendance and awards but publishes only one cost of attendance for full time for the purpose of illustration. Hence, the college will start publishing all COA for all enrollment categories in the student financial aid handbook as a published guideline for awarding • A timeline that aligns record origination with student registration/enrollment confirmation to minimize errors and fully utilize the published Pell Recalculation Date (PRD) in the student financial aid handbook b. The SOP will be reviewed annually. 2. Staff Training and Certification a. FAO staff will participate in mandatory annual internal training and refresher workshops on the EDExpress system, COD reporting procedures, and Title IV compliance. The first round of enhanced training will be completed by August 30, 2025]. Staff will also complete Federal Student Aid (FSA) training modules related to COD and verification processes to ensure understanding of federal expectations and system updates. 3. Manual Data Verification Protocol • The Financial Aid Office (FAO) will implement a structured manual data verification protocol to ensure accuracy when transferring information from the Student Information System (SIS) to EDExpress. This protocol will include: Use of pre-submission checklists to verify each student’s cost of attendance (COA), enrollment status, and other required data fields against the official records in the SIS. • Designated FAO staff will perform a two-tiered review process, where one staff member enters data and another independently verifies accuracy prior to COD submission. • Maintenance of record logs for each batch of COD submissions, documenting the review steps taken and any discrepancies corrected before submission. 4. Oversight and Accountability a. The Director of the Financial Aid Office (FAO) will be responsible for monitoring adherence to COD reporting requirements to ensure accuracy and compliance. This includes tracking staff training completion related to EDExpress and Title IV regulations, conducting quarterly internal reviews of origination and disbursement records, and verifying the correct use of current cost of attendance figures and enrollment status classifications. The Director will document findings, implement corrective actions as needed, and provide quarterly progress reports to the Vice President for Enrollment Management and Student Services (VPEMSS). Contact: VPEMSS Completion Date: September 30, 2025

Single Audit Report Submission Federal Agency: Various Federal Program Name: Research and Development Cluster, Education Stabilization Fund, Supplemental Nutritional Assistance Program (SNAP), Federal Supplemental Educational Opportunity Grant Program, Federal Pell Grant Program; Federal Direct Student Loans; Federal Work Study Program, Federal Perkins Loan Program Assistance Listing Number: Various Recommendation: We recommend the University implement and maintain an effective system of internal controls over timely submission of the single audit reporting package. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As a result of staffing turnover in the Finance area, the University engaged consulting support to assist in readying for financial statementpreparation and the audit of fiscal years ending 6.30.23 and 6.30.24, with oversight from the University management. The University will develop a fiscal year‐end close process that includes submission of the single audit report. Name(s) of the contact person(s) responsible for corrective action: Melissa Hicks, Controller Planned completion date for corrective action plan: December 31, 2025

240 Day Escheatment Federal Agency: U.S. Department of Education Federal Program Name: Federal Supplemental Educational Opportunity Grant Program; Federal Pell Grant Program; Federal Direct Student Loan; Federal Work Study Program Assistance Listing Number: 84.007; 84.063; 84.268; 84.033 Recommendation: We recommend the University review its policies and procedures related to outstanding student refund checks to ensure they are being returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management of the areas involved in the escheatment process will develop a business procedure addressing this finding. A regular process will be implemented to ensure the University complies with requirements. The process will be integrated with our month‐end close process to ensure that it occurs in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Melissa Hicks, Controller, Varah Barnett, Director of Financial Aid, Danyel Tolbert, Bursar Planned completion date for corrective action plan: December 31, 2025

Fiscal Operations Report and Application to Participate (FISAP) Federal Agency: U.S. Department of Education Federal Program Name: Federal Supplemental Educational Opportunity Grant Program, Federal Pell Grant Program; Federal Direct Student Loans; Federal Work Study Program; Federal Perkins Loan Program Assistance Listing Number: 84.007; 84.063; 84.268; 84.033; 84.038 Recommendation: We recommend management maintain and safeguard all necessary data and documentation to support the FISAP. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of March 2024, the Office of Financial Aid has been completely restructured and has new financial aid administrators. The Office of Financial Aid now performs a manual check to ensure FISAP information is in Banner. This entails maintaining worksheets within COD updated. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: July 1, 2024

Federal Perkins Loan Program Reconciliation Federal Agency: U.S. Department of Education Federal Program Name: Federal Perkins Loan Program Assistance Listing Number: 84.038 Recommendation: We recommend reviewing procedures around Perkins Loan Program funds and implementing reconciliations and review to the third‐party servicer reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university is in the process of implementing policies and procedures regarding reconciliations for Perkins loan services managed by a 3rd party supplier. Name(s) of the contact person(s) responsible for corrective action: Danyel Tolbert ‐Bursar Planned completion date for corrective action plan: June 30, 2025

Federal Perkins Loan Program Third‐Party Servicer Federal Agency: U.S. Department of Education Federal Program Name: Federal Perkins Loan Program Assistance Listing Number: 84.038 Recommendation: We recommend reviewing procedures and requirements regarding Perkins third party service providers and ensure compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university is in the process of implementing policies and procedures regarding reconciliations for Perkins loan services managed by a 3rd party supplier. Name(s) of the contact person(s) responsible for corrective action: Danyel Tolbert ‐Bursar Planned completion date for corrective action plan: June 30,2025

Direct Loan Reconciliation Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loan Assistance Listing Number: 84.268 Recommendation: We recommend management maintain proper recordkeeping and retention of documentation and review of such documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented new procedures surrounding reconciliations of direct loans. The Director of Financial Aid meets monthly with Finance to review reconciliations from Banner and Common Origination Disbursement (COD), which also houses historical data. In addition, the Office of Financial Aid maintains a share drive with all reconciliations. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: July 1, 2024

Federal Perkins Loan Program Record Retention Federal Agency: U.S. Department of Education Federal Program Name: Federal Perkins Loan Program Assistance Listing Number: 84.038 Recommendation: We recommend that the University keep MPNs for loans for the three‐year retention period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented procedures to ensure that all requirements for loan borrowers are completed. One of these additional internal controls, is that the loan will not disburse unless MPN information is loaded into Banner. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: July 1, 2024

Enrollment Reporting to the National Student Loan Database System (NSLDS) Federal Agency: U.S. Department of Education Federal Program Name: Federal Pell Grant Program; Federal Direct Student Loan Assistance Listing Number: 84.063; 84.268 Recommendation: We recommend the University evaluate its procedures and review policies in overseeing submissions to the NSLDS completed by the third‐party servicer. Additionally, we recommend the University review its policies and procedures on reporting enrollment information to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented additional procedures surrounding NSLDS ensuring the information uploaded is timely and accurate. Enrollment is now reported by the Registrar's office to NSLDS and a quality control check is performed by reconciling a Banner system report to the NSLDS input report. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: June 1, 2025

Cash Management Federal Agency: U.S. Department of Education Federal Program Name: Federal Supplemental Educational Opportunity Grant Program; Federal Pell Grant Program; Federal Direct Student Loan; Federal Work Study Program Assistance Listing Number: 84.007; 84.063; 84.268; 84.033 Recommendation: We recommend management maintain proper recordkeeping and follow policies and procedures that are in effect at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented new procedures surrounding reconciling drawdown requests and approvals. The Director of Financial Aid meets monthly with Finance and Grants Accounting to review reconciliations. Finance now submits drawdown requests to the CFO for prior‐approval and keeps them documented. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: July 1, 2024

Return of Title IV Calculation Federal Agency: U.S. Department of Education Federal Program Name: Federal Supplemental Educational Opportunity Grant Program; Federal Pell Grant Program; Federal Direct Student Loan; Federal Work Study Program Assistance Listing Number: 84.007; 84.063; 84.268; 84.033 Recommendation: We recommend management review policies around determining students who withdrew and if a return of Title IV funds calculation is necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Student Financial Aid Office now works closely with the Registrar to verify R2T4 calculations. In the event a student withdraws and receives award funds, the R2T4 process provided by the Registrar takes place to calculate the refund amount owed by the student. If no payment arrangement is arranged, the student will be sent to Collections. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: April 1, 2025

Exit Counseling Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loan Assistance Listing Number: 84.268 Recommendation: We recommend the University review its policies and procedures around sending exit counseling information to students to ensure students are receiving proper counseling. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University now utilizes Banner System Optimization to develop a message alert within the Student Portal (Wired) when a withdrawal date is entered. This message servers as a reminder for the student to complete exit counseling. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: November 1, 2024

Awarding of Title IV Aid Federal Agency: U.S. Department of Education Federal Program Name: Federal Supplemental Educational Opportunity Grant Program; Federal Pell Grant Program; Federal Direct Student Loan; Federal Work Study Program Assistance Listing Number: 84.007; 84.063; 84.268; 84.033 Recommendation: We recommend the University implement policies to review all student award packages at the start of the academic year to ensure no over awarding exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University now has a procedure in place so that enrollment is frozen one week prior to disbursing aid. This allows the University to perform a quality check on the inputs. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: February 7, 2025

Awarding of Pell Grant Federal Agency: U.S. Department of Education Federal Program Name: Federal Pell Grant Program Assistance Listing Number: 84.063 Recommendation: We recommend management review individual student calculations of Pell awards to ensure no additional errors in awards disbursed to students. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented internal controls within the Banner system that will not allow a miscalculation to occur. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: November 1, 2024

Verification Federal Agency: U.S. Department of Education Federal Program Name: Federal Supplemental Educational Opportunity Grant Program; Federal Pell Grant Program; Federal Direct Student Loan; Federal Work Study Program Assistance Listing Number: 84.007; 84.063; 84.268; 84.033 Recommendation: We recommend management retain electronic files of student verification documentation more securely within school systems/networks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented procedures regarding document retention to ensure that student statements are properly processed and retained. The University now also uploads all files to a central share drive for record keeping purposes. Name(s) of the contact person(s) responsible for corrective action: Varah Barnett, Director of Financial Aid Planned completion date for corrective action plan: July 1, 2024