Corrective Action Plans

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Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees wit...
Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON’s Office of Student Financial Aid will implement a process that ensures all required documentation is retained. Employees of the Student Financial Aid Office will be trained and PSON will be in compliance with the requirements in the Federal Student Aid Handbook. Name of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.
Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying an...
Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying and documenting disbursement and enrollment dates, academic year parameters, and cost of attendance calculations prior to COD submission. This will include additional layers of review to ensure timely and accurate reporting. These policies and procedures will be implemented by December 31, 2025.
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.
Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was du...
Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was due to error entry, neighboring lines. 2. motor vehicle theft and a weapons violation was not reported to the Department of Education. The issue was due to carelessness. These were correctly reported in the Annual Security Report. Usually, the Annual Security Report and report to the Department of Education is prepared and completed by the Student Services Coordinator and the Administrative Dean based on the statistic report from the school and the Police Department in August/September. Because the college was engaged in the self-study for accreditation, everyone was extremely busy at that time. Errors might occur when doing things in a hassle way. Actions Taken or Planned: 1. Corrections were made in the Annual Security Report and in the report to the Department of Education. Two corrections were made in the DOE website: Criminal Offenses - Public Property: For 2023, line J (motor vehicle theft) was changed from 0 to 1. Arrests - Public Property: For 2023, line a (weapon) was changed from 0 to 2 2. New Hire: The college is in the process of hiring a new Student Services Coordinator. This individual will work with the Administrative Dean for ensuring the accuracy and timelines of reporting moving forward. 3. A strengthen double-check system will be established to ensure the accuracy of all reporting. Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu
Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balan...
Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balance Authorization Form was on file, the refund was processed after the award year had ended, rather than within the required timeframe. In the past, students were always allowed to keep funds in their Populi accounts for future use regardless of the loan award year, and it had not previously been indicated that this practice was not allowed. Actions Taken or Planned: We have reviewed our internal procedures and will strengthen oversight of award year deadlines to ensure that all credit balances are refunded within the required timeframe. Moving forward, the financial aid and accounting teams will implement a compliance checklist and establish calendar reminders to prevent similar delays. Additionally, we will revise the wording on our Credit Balance Authorization Form to read: “Leave the funds in my account and any remaining funds from the current award year in my account up to the end of the loan period.” Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu
View Audit 370123 Questioned Costs: $1
Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Cur...
Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Currently, we update enrollment maintenance every two months, typically on the day prior to the scheduled dates. We now understand that enrollment status updates must be completed within 15 days after the scheduled date. Actions Taken or Planned: We have reviewed the enrollment maintenance schedule and adjusted our process to ensure compliance with the requirement. Moving forward, enrollment status will be updated within 15 days after the scheduled date. This adjustment will be fully implemented starting from the next scheduled update on 09/30/2025. 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu
Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further a...
Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further action is required until future needs arise for Atrium Health CMHA to obtain FEMA funding awards at which time management will ensure all documentation supporting the process and key decisions are retained.
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that appropriate training and process design for Jenzabar Financial Aid (JFA) system are implemented to accurately capture and retain all data required for FISAP report...
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that appropriate training and process design for Jenzabar Financial Aid (JFA) system are implemented to accurately capture and retain all data required for FISAP reporting. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT sys...
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are ma...
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are maintained. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign various processes and w...
Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign various processes and work flows. This project is expected to address the gap in SFA transactional review and approval internal controls that are arising due to the SFA program size, limited number of subject matter experts, and the management turn; and result in mitigating controls and policies being implemented to ensure the accuracy and completeness of all SFA transactions. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign the reporting structure...
Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign the reporting structures, process work flows, and procedures within the Student Financial Aid (SFA) office, the Business office, and Student Services specifically as those areas relate to student status and records. It is expected this engagement will ensure that the internal controls within the entire SFA office will improve, including that the SFA IT Systems are documented and tested and that any compensating controls identified as needed are implemented. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action plan. .
Corrective Action: The College has performed a full review of processes and controls related to credit-balance payments within 14-days to ensure accuracy moving forward and corrected the concern in the 2024 fall semester. Contact Person: Michael Hamilton, Dean of Student Success Anticipated Completi...
Corrective Action: The College has performed a full review of processes and controls related to credit-balance payments within 14-days to ensure accuracy moving forward and corrected the concern in the 2024 fall semester. Contact Person: Michael Hamilton, Dean of Student Success Anticipated Completion Date: completed
Corrective Action: A monthly reconciliation process was put into place (July 2024) to include control reporting of all status changes to ensure accuracy and timeliness of student status changes from the college’s student information system to National Student Clearinghouse to NSLDS. However, additio...
Corrective Action: A monthly reconciliation process was put into place (July 2024) to include control reporting of all status changes to ensure accuracy and timeliness of student status changes from the college’s student information system to National Student Clearinghouse to NSLDS. However, additional training for Registrar and Financial Aid staff is in progress to include a repeated review of processes and controls related to monthly Student Information System – Clearinghouse – NLSDS reconciliation. This review will include a review of how program start dates (semester and session) vs. course starts affect reporting, as well as how multiple student status changes to registration affect reporting. The College’s third-party servicer, National Student Clearinghouse, is assisting in this training as well as the update of policies, processes, and controls, as well as the maintenance of evidentiary documentation, to ensure accuracy moving forward. Contact Person: Lori Arnder, College Registrar and Enrollment Manager Anticipated Completion Date: October 1, 2025
Corrective Action: The College is in process to include a full review of processes and controls related to monthly COD/NLSDS reconciliation. The College’s third-party servicer, Global Financial Services, is assisting in this training as well as the update of policies, processes, and controls, as wel...
Corrective Action: The College is in process to include a full review of processes and controls related to monthly COD/NLSDS reconciliation. The College’s third-party servicer, Global Financial Services, is assisting in this training as well as the update of policies, processes, and controls, as well as the maintenance of evidentiary documentation, to ensure accuracy moving forward. Contact Person: Michael Hamilton, Dean of Student Success Anticipated Completion Date: October 1, 2025
As of today, September 29, 2025, the organization has fully implemented procedures in Populi to update enrollments to actual final status within the required 30 days. This data will be reported to our third-party servicer RGM in real-time. The academic and administrative teams review these reports.
As of today, September 29, 2025, the organization has fully implemented procedures in Populi to update enrollments to actual final status within the required 30 days. This data will be reported to our third-party servicer RGM in real-time. The academic and administrative teams review these reports.
Over the past two months in August and September, the board has reviewed the budget and the organization has sharply reduced staff and facility costs at both the Austin and Berkeley campuses. This will ensure that the organization qualifies for at least a 1.0 on the composite score and qualify for a...
Over the past two months in August and September, the board has reviewed the budget and the organization has sharply reduced staff and facility costs at both the Austin and Berkeley campuses. This will ensure that the organization qualifies for at least a 1.0 on the composite score and qualify for a letter of credit alternative or provisional certification alternative to meet the fiscal responsibility requirements through the 2025 fiscal year audit. As of today, September 29, 2025, expense reductions have been implemented.
Sentara Health and Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: PBMares, LLP 701 Town Center Drive, Suite 900 Newport News, VA 23606 Audit period: Year ended December 31, 2024 The ...
Sentara Health and Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: PBMares, LLP 701 Town Center Drive, Suite 900 Newport News, VA 23606 Audit period: Year ended December 31, 2024 The finding from the year ended December 31, 2024 schedule of findings and questions costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FEDERAL AWARDS FINDING A. Significant Deficiency in Internal Control over Compliance Finding 2024-001: Student Financial Assistance Cluster - Federal Assistance Listing Number 84.268 - Significant Deficiency in Internal Control over Enrollment Reporting to National Student Loan Data System (NSLDS) Recommendation: Internal controls should be implemented to ensure that all enrollment status changes, including withdrawals occurring outside of standard roster cycles, are reported to NSLDS within the required timeframe. This should include submitting out-of-cycle enrollment updates to the Clearinghouse when necessary. This is not a repeat finding. Corrective Action Plan: 1. The Registrar will create a report that captures students who withdrew from the college to include all students in all program cycles. This report will capture withdrawal activity that occurs within and falls outside of each reporting period. 2. The report will be manually cross-referenced with enrollment data in the student information system. The responsible parties for ensuring this corrective action is employed are the Registrar and the Assistant Registrar of the College. They will be overseen by Cindy Mabie, Assistant Dean for Student Services. Timeline for Completion: The new process will go into effect October 1, 2025. If there are questions, please contact Cindy Mabie, Assistant Dean for Student Services at Cmabie@sentara.edu.
Actions Taken: The institution has implemented an automated process for Exit Counseling to ensure compliance with Title IV requirements. As of August 2025, the system has been configured to automatically send an exit counseling notification to students when they enter one of the following statuses: ...
Actions Taken: The institution has implemented an automated process for Exit Counseling to ensure compliance with Title IV requirements. As of August 2025, the system has been configured to automatically send an exit counseling notification to students when they enter one of the following statuses: • Withdrawal • Graduation • Less than half-time enrollment System Workflow: When a student’s status changes, the system immediately generates and sends an email alert containing exit counseling instructions and the necessary links for completion. This ensures timely notification without requiring manual tracking by staff. Monitoring and Compliance: • Reports will be reviewed monthly to confirm that all required students received the exit counseling notifications. • Any discrepancies will be immediately investigated and resolved. Outcome: This automation eliminates the manual process previously in place, ensuring 100% notification compliance and greatly reducing the likelihood of future deficiencies in this area.
Actions Taken / Planned The institution recognizes the importance of timely processing of Title IV credit balances and refunds. To address the deficiencies identified: 1. Short-Term Action (Current Practice): Effective immediately, all staff are required to submit for processing refunds within 24 ho...
Actions Taken / Planned The institution recognizes the importance of timely processing of Title IV credit balances and refunds. To address the deficiencies identified: 1. Short-Term Action (Current Practice): Effective immediately, all staff are required to submit for processing refunds within 24 hours of identifying a credit balance. Staff will also promptly correct any errors discovered during the reconciliation process. o Monitoring: Supervisors will conduct weekly reviews to ensure compliance with this 24-hour policy. o Training: Refresher training on Title IV credit balance processing has been provided to all relevant staff as of September 2025. o Instead of one ‘check run’ per week, numerous ‘check runs’ may be necessary to ensure 14 day window is met. 2. Long-Term Action (System Integration and Automation): The institution is actively working to integrate QuickBooks into our Student Information System (SIS) to automate Title IV and refund documentation. o This integration will streamline the reconciliation process, reduce manual errors, and ensure consistent, timely processing of refunds. o Projected Completion Date: Implementation and full automation are expected to be completed within 9–12 months, with a target date of September 2026. Expected Outcome: These measures will ensure timely and accurate processing of Title IV credit balances, improve compliance, and reduce the risk of future findings.
We concur with this finding. The County of York has hired a Human Services Director of Finance to assist with improving systems and financial processes within the Human Services (HS) divisions. The HS Executive Director and Director of Finance are recommending engaging an expert Consultant to assist...
We concur with this finding. The County of York has hired a Human Services Director of Finance to assist with improving systems and financial processes within the Human Services (HS) divisions. The HS Executive Director and Director of Finance are recommending engaging an expert Consultant to assist the County’s Children & Youth Fiscal team in getting caught up on internal system timelines, as well as delayed reporting. The Consulting company will also be working to adequately train the Children & Youth Fiscal team for development purposes.
We concur with this finding. Children, Youth and Families will explore ways to better track the State Fiscal Year and County’s Calendar Year side-by-side. The Children & Youth Fiscal team will work with the Director of Finance to implement reconciliation processes and will prioritize timeliness of r...
We concur with this finding. Children, Youth and Families will explore ways to better track the State Fiscal Year and County’s Calendar Year side-by-side. The Children & Youth Fiscal team will work with the Director of Finance to implement reconciliation processes and will prioritize timeliness of reporting.
The County will ensure that procedures are in place to ensure support is provided for review and approval of eligibility determination.
The County will ensure that procedures are in place to ensure support is provided for review and approval of eligibility determination.
Finding 1156667 (2024-006)
Material Weakness 2024
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
Management’s Views and Corrective Action Plan 2024-002 – Non-compliance with Disbursements to or on behalf of students Grantor: U.S. Department of Education Program Name: Student Financial Assistance Cluster Award Names: Federal Supplemental Educational Opportunity Grants (FSEOG), Federal Pell Grant...
Management’s Views and Corrective Action Plan 2024-002 – Non-compliance with Disbursements to or on behalf of students Grantor: U.S. Department of Education Program Name: Student Financial Assistance Cluster Award Names: Federal Supplemental Educational Opportunity Grants (FSEOG), Federal Pell Grant Program and Federal Direct Student Loans Award Year: 1/1/2024 - 12/31/2024 Award Number: Not applicable Assistance Listing Numbers: 84.007, 84.063 and 84.268 Management’s Response Management has sent disbursement notifications to students and tracked aspects of the notifications via the AHN Schools of Nursing’s (the “Schools”) student portal. Each notification was sent by email to the student, and an activity was logged in the student’s audit log and activity tracking with the student portal. From this process, management agrees that the Schools were unable to extract the exact disbursement details that were sent via the disbursement email. Additionally, the Schools could not replicate the disbursement email that is sent to the student. To ensure all reporting requirements are met, the Schools have ensured that a copy of the disbursement email will be sent to both the student and the institution. The Schools have already modified the disbursement notification process by adding a secondary email address to the disbursement notifications. A copy of each notification will be sent to campuscafesuperuser@ahn.org to ensure a copy of the notifications will be available for future audits. Management agrees that there was no receipt of affirmative confirmation for one student and no available signed attestation to verify voluntary consent to participate in electronic transactions for one student. The lack of receipt and documentation was due to a human clerical error. Management has communicated reminders of the related requirements, as well as the Schools policies and procedures to the personnel. In addition, management is in process of recruiting an additional Financial Aid Officer, who will act as an additional layer of review and cross-checks to ensure documentation is retained appropriately. Anticipated Completion Date As of the date of this report the above noted process has been updated and is current procedure. Management is actively recruiting for an additional Financial Aid Officer and is working to fill the open position as soon as possible. Responsible Parties • Amy Stoker, Director of AHN Schools of Nursing • Sarah Loomis, Director of Financial Aid of AHN Schools of Nursing • Rosanna Sarantinoudis, Student Accounts Associate and Registrar of West Penn Hospital School of Nursing • Natalia Wassel, Student Accounts Associate and Registrar of West Penn Hospital School of Nursing
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