Corrective Action Plans

2023-002 – Reporting to the Common Origination and Disbursement (COD) System Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network agrees with the finding, and will make the following enhancements to the process: A reconciliation between the amounts of St. Luke’s School of Nursing disbursements compared to COD disbursement records will be completed monthly starting Q4 2024 by downloading the SAS file from COD. Starting FY 2024, these reconciliations will be completed monthly. After Originating a PELL Grant or a Direct Loan, the Financial Aid Office will check COD to ensure that the Origination came back with an “Accepted” value before any disbursement can be made. The student will be notified of the error and Direct Loan proceeds will be refunded to the Department of Education. This will ensure the student was properly reported and sent a direct loan disbursement notification as required to notify the student of the date and amount of disbursement, the right to cancel and procedures to cancel. The Network is implementing this process beginning in Q4 of FY2024. All disbursement records for PELL Grant and Direct Loan payments will be sent to COD on the disbursement date and no later than 15 days of the disbursement occurring. Starting Q4 of FY 2024, all PELL Grant and Direct Loan payments will be checked to ensure that they are sent to COD within this acceptable date range. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.

2023-001 – Gaps in General Controls for SFA/COD Process (Significant Deficiency) Cluster: Student Financial Assistance Sponsoring Agency: Department of Education Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Numbers: Not applicable Assistance Listing Titles: Federal Pell Grant Program and Federal Direct Student Loans Assistance Listing Numbers: 84.063 and 84.268 Award Year: 2022-2023 Pass-through entity: Not applicable The Network has controls for the student financial aid program, monitored by the Student Financial Aid Office. The Network agrees with the finding regarding the retention of support and documentation of the reviews and approvals in the financial aid process. Going forward the Network will enhance the documentation and retention of support of proper review and approval that will evidence the appropriate segregation of duties. The Network is implementing this process beginning in Q4 of FY2024. For inquiries regarding this finding, please contact Lisa Storck, Senior Associate Dean, and Joe Zelasko, Senior Financial Aid Coordinator, who are responsible for the corrective action.

The district Information Technology Services unit is currently working with Ellucian to configure and implement the Time and Effort reporting module within the BANNER timekeeping system. This will allow departments to monitor time and effort activity and ensure that allowable costs are tracked and charged to the appropriate programs and services. This should be completed by June 30, 2024.

2023-004 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Criteria: 34 CFR 668.22 (a)(1) states “When a recipient of title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of title IV grant or loan assistance that the student earned as of the student's withdrawal date in accordance with paragraph (e) of this section.” 34 CFR 668.22 (e)(2) states, “The percentage of title IV grant or loan assistance that has been earned by the student is - (i) Equal to the percentage of the payment period or period of enrollment that the student completed (as determined in accordance with paragraph (f) of this section) as of the student's withdrawal date, if this date occurs on or before - (A) Completion of 60 percent of the payment period or period of enrollment for a program that is measured in credit hours; or…” 34 CFR 668.22(j) notes, “(1) An institution must return the amount of title IV funds for which it is responsible under paragraph (g) of this section as soon as possible but no later than 45 days after the date of the institution's determination that the student withdrew as defined in paragraph (l)(3) of this section. The timeframe for returning funds is further described in § 668.173(b).” An institution must notify the student of a post-withdrawal disbursement of Federal Direct Loans used to credit the student’s account for outstanding charges (34 CFR 668.22). Condition: The College did not accurately complete refund calculations in the Spring. In review of the Spring 2023 calculations the number of days in the break was not calculated correctly, resulting in the incorrect days in Spring 2023 return of Title IV funds calculations. As a result of the incorrect number of days, the amounts of Title IV amounts returned for all withdrawn students were incorrectly calculated for 1 out of the population of 4 (25%) total withdrawal calculations. We consider this finding to be an instance of noncompliance in relation to Special Tests and Provisions. Statistical sampling was not used in making sample selections. Views of Responsible Officials: After years of completing a manual calculation we had switched to a full automated process. Going forward we will be completing a manual calculation to compare to the automated response to ensure the correct number of days are used. Responsible Person: Andra Butler, Vice President of Financial Aid Implementation Date: October 2023

2023-003 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Criteria: 34 CFR 685.203 states, "A student may not receive a Federal Direct Subsidized Loan amount that exceeds the student’s estimated cost of attendance for the period of enrollment less the borrower’s expected family contribution and estimated financial assistance for that period.” Condition: The College did not properly disburse direct loans for 1 out of 40 students (2.5%). Views of Responsible Officials: The financial aid office staff will complete the packaging aid and loans learning tracks on the Federal Student Aid Training Center. The staff will complete this training annually to ensure compliance of all regulations. Responsible Person: Andra Butler, Assistant Vice President of Financial Aid Implementation Date: October 2023

Condition: We identified one instance where a student’s program enrollment effective date did not match the institution’s records. Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The College will review enrollment reporting procedures to determine where additional review of data and monitoring of third-party servicer data can be implemented to ensure accurate reporting. Name(s) of the contract person(s) responsible for corrective action: Chris Peterson – Director of Student Financial Aid, Stacy Sharp – Director of Registration and Records, and Laura Beyers – Director of Registration and Records Planned completion date for corrective action plan: June 30, 2024

Condition: The College did not maintain required Tier One servicer information on their website and did not disclose the URL to the Department of Education. Recommendation: We recommend the College implement procedures to identify requirements about disclosures when using third-party servicers and to implement such requirements on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The College has updated the student refund webpage to include the contract maintained with the Tier One servicer and will disclose the URL to the Department of Education. The College will adjust internal review procedures to ensure disclosure requirements are identified and implemented. Name(s) of the contract person(s) responsible for corrective action: Kailey Block – Controller and Jennifer Gilsdorf – Assistant Controller Planned completion date for corrective action plan: May 1, 2024

Corrective Action Plan The Student Financial Services department has undergone process improvements over the previous fifteen months. The processes and procedures for the calculation and Return of Title IV funds have been reviewed and staff in charge of these functions have been trained. Effective for the Fall semester of FY24, rather than just a sampling, every calculation has been, and continues to be, double checked by another staff member who does recalculations before the revised award letter is sent and funds returned. Management is also in the process of implementing a change in staff areas of responsibility and will be moving the individual whose errors have been most frequent to administer another, less complex process. Timeline for Implementation of Corrective Action Plan The corrective action plan was implemented as of October 1, 2023. Contact Person Karen Grant, Financial Aid Director

The School will work with its University Accounting Services (UAS) representative to obtain the UAS compliance examination report on a timely basis each year. If UAS is unable to provide the compliance examination report on a timely basis, the School will consider finding another vendor to assist with the billings, collections and due diligence for the Federal Perkins Loan Program. Responsible Parties: Nathaniel Hibler – Vice President of Finance (802) 831-1204 Emily Parker – General Ledger Accountant (802) 831-1271 Estimated Completion Date: June 30, 2024

The Registrar’s office of Vermont Law and Graduate School (the School) will continue to run monthly enrollment reports and upload them into the Clearinghouse through their website. Any anomalies or glitches discovered by the Registrar’s Office will be discussed with the Information Technology department who will contact the software manufacturer (Jenzabar). If a patch is deemed necessary, it will be installed through an update by the Software Manufacturer and Information Technology. Responsible Parties: Maureen Moriarty – Registrar (802) 831-1235 Melissa Erickson – Director, Financial Aid (802) 831-1235 Estimated Completion Date: June 30, 2024

Recommendation: We recommend that the University implement processes and/or internal controls that ensure that a student has completed entrance counseling prior to disbursing Direct Loans proceeds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The error was caused by an abrupt resignation of loan processing staff and a lack of redundancy in critical processing areas. A staff member who was new to loan administration originated a loan then disbursed it to the student the moment it returned from COD. This rapid processing was in response to the student’s dire need for housing funding; however, the expedited process inadvertently circumvented the Banner system’s safeguards. This previously unknown issue has been resolved with the following systems updates: 1. Improved training and documentation 2. The previous system relied on RRAAREQ to prevent disbursement; however, the new system has a secondary and tertiary check that prevents disbursement. Both the entrance counseling tick box on RLADLOR and a positive indicator on the table that captures raw entrance counseling data (RPILECS) must align for a loan disbursement. Name of the contact person responsible for corrective action: Elijah Herr, Director of Financial Aid Planned completion date for corrective action plan: March 2024

Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates reported to NSLDS agree to the enrollment effective dates per the University’s records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: It appears that the erroneous enrollment status effective date reported is equal to the certification date for the enrollment file that was sent to the National Student Clearinghouse (NSC). We are researching how the certification date may have been substituted as the enrollment status effective date. Name of the contact person responsible for corrective action: Nicolle DuPont, Associate Registrar Planned completion date for corrective action plan: April 2024

Recommendation: We recommend that the University strengthen its internal controls over monitoring the academic engagement for students that are enrolled in distance education courses at the University. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: The University had already identified this weakness prior to the Single Audit. To address this weakness, Portland State University has implemented a robust Initiation of Attendance protocol that is required of every instructor. Faculty were informed of: 1) Federal regulations related to initiation of attendance. 2) The standards used for documenting academic engagement in an online environment. 3) The method by which the instructor positively indicates that an online student has academically engaged in the course. The University has provided written policies on its website and engaged in a vigorous communication plan with both faculty and students. Compliance with the new policy is monitored through weekly reporting, and instructors who have not documented the initiation of attendance are referred to their dean, chair or department head. Prior to any reduction in Title IV aid, students are notified of any missing documentation and encouraged to speak with their instructors immediately. Last, reconciliation reports are monitored by the financial aid office for discrepancies and any conflicting information is resolved by contacting the instructor. Name of the contact person responsible for corrective action: Elijah Herr, Director of Student Financial Aid, Cindy Baccar, Associate Vice Provost & University Registrar and Karenna Wait, Director of Enterprise Applications. Planned completion date for corrective action plan: September 2023

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A loan disbursement notification was sent to the student for both the fall 2022 and spring 2023 semesters. We can document the spring 2023 loan disbursement notification was sent but are unable to document the date. Our internal processes dictate that the notification would normally be sent on the date of disbursement. We will develop and implement additional controls to effectively capture a student’s disbursement notification to ensure that both a record of the notification and the date are maintained. Anticipated Completion Date: August 15, 2024

Individual Responsible for Corrective Action: Linda Fleischman, Registrar Corrective Action: The Registrar’s Office will reach out to Jenzabar to determine what is triggering the incorrect program start date. Beginning with the summer 2024 students, each new student record will be reviewed prior to the initial National Student Clearinghouse submission to ensure that the start date is being reported correctly. Anticipated Completion Date: August 15, 2024

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. The break days for fall 2022 were not properly calculated to include a break of 5 days. We will develop and implement a process within Student Financial Services to audit all R2T4 records for accuracy, completeness, and consistency regarding length of academic periods. Anticipated Completion Date: August 15, 2024

Individual Responsible for Corrective Action: Everett Jeter, Director of Compliance Corrective Action: The error falls into the category of human oversight rather than fundamental misunderstanding of the regulation or timing of processes. A transfer monitoring record was originated for this student approximately six weeks prior to the spring 2023 semester. We did not receive a transfer monitoring response from NSLDS and therefore student was awarded aid as a non-transfer student. We recognized the oversight and the student’s award amount was updated to maintain appropriate annual limit during the spring 2023 semester. We will develop and implement additional controls to effectively capture transfer students for monitoring when a response from NSLDS is not received to ensure award accuracy. Anticipated Completion Date: August 15, 2024

I will ensure the Financial Aid Office works closely with the Accounts Payables department to monitor that all Title IV refund checks have been cashed after 30 days of issuance of the refund. If a check has not been cashed a new check will be reissued immediately. If, after 30 days of the reissuance, the check has not been cashed then the funds will be returned to the Department of Education within the mandated 45-day period.

We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process and procedures documentation as an internal control measuring tool to ensure that Administrative Withdrawals (AW) and Withdrawals for lack of attendance (WA) that affect student emollment are identified immediately. Staff in the Financial Aid and the Registrar's office will actively take part in training workshops and webinars provided by the Depatiment of Education and NASF AA for continuing education to stay abreast of new developments and best practices in the industry.

2023-003 Significant Deficiency: National Student Loan Data System (NSLDS) Report (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268 and Federal Pell Grant Program, ALN #84.063) (Repeat finding of 2022-001) Name of Contact Person Casey Reagan, Registrar, is responsible for ensuring student enrollment status for changes in enrollment are correct. Melissa White, Director of Financial Aid, is responsible for uploading the enrollment status reports to clearinghouse. Corrective Action Planned During the audit, it was noted that Tusculum reported student enrollment status at changes in enrollment incorrectly. The Registrar and the Director of Financial Aid will work in conjecture to determine why the report that is pulled to upload to clearinghouse is not pulling accurate student enrollment status changes in enrollment. Once the error is identified and fixed, financial aid will pull the report and check to ensure everything is pulling correctly. Then, each month as the report is pulled, a random sampling of students will be pulled out of the report to be checked against the enrollment records to ensure that the report continues to pull correctly. Anticipated Completion Date The Registrar and Director of Financial Aid still needs to identify where the error is occurring. It is the goal to have this issue resolved before the end of the spring 2024 semester.

2023-002 Material Weakness: Gramm-Leach-Bliley Act (GLBA) (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) Name of Contact Person Casey Reagan, Registrar, and Chris Summey, Head of our IT Department, are the Designated Employees in charge of overseeing the GLBA policy. Corrective Action Planned During the audit, it was noted that Tusculum did not fully address all of the requirements as described by 16 CFR 314.4. In addition, the application of the comprehensive information security program was not effectively administered by the University for the 2023 year. In fall 2023, IT, the Registrar, and the Director of Financial Aid met to discuss making sure that all of the new pieces of the GLBA policy were being implemented properly. In December of 2023, IT began the latest vulnerability scan and risk assessment to be in compliance with the risk assessment requirements of the GLBA Policy. This assessment should be completed by the end of spring 2024. The University is also working on updating its GLBA policies and procedures to align with the GLBA Policy. Anticipated Completion Date This process is currently ongoing and it is the University's goal to have ongoing GLBA policies updated and the risk assessment completed before the end of the 2023-2024 academic year.

Finding number: 2023-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063 Award year: 2023 Corrective Action Plan: The Registrar’s Office is responsible for enrollment reporting to the National Student Clearinghouse. After consulting with the Interim Registrar, it was determined that the two students in question were manually updated in the National Student Clearinghouse. There was no recollection regarding why the particular effective dates were used. The two student records have been corrected both in the National Student Clearinghouse and the National Student Loan Data System. Going forward, the Registrar’s Office will diligently ensure that the proper reporting of effective dates is submitted to the National Student Clearinghouse. We do not foresee any future issues. Timeline for Implementation of Corrective Action Plan: The corrective action plan has been implemented as of March 2024. Contact Person Despina Lambropoulos, Director of Financial Aid Shawna Lind, Interim Registrar

Name of Responsible Individual: Montague Blount Corrective Action: The University Registrar will develop a plan to ensure appropriate cross-training, position backup, and a system of proper checks and balances to improve quality control and continuity in executing core functions in the Registrar's Office. Enrollment reporting is a critical function that will be prioritized in the implementation of the referenced plan. Anticipated Completion Date: June 30, 2024

Names of Responsible Individuals: Chad Wick, Director Financial Aid and Brian Emery, Associate Director Financial Aid Corrective Action: The Financial Aid office made several staffing changes in 2022-2023. The newly hired staff did not receive the proper training to perform their roles effectively. This led to errors identifying and calculating the unearned amount of Title IV assistance to be returned. The previous Financial Aid Director was terminated before the prior corrective action plan could be fully completed. New leadership, in collaboration with the Office of Information Technology, has developed an automated weekly report confirming student withdrawal dates. The report is scheduled to be emailed to Financial Aid office every Friday. The Financial Aid Director reviews the report and identifies Title IV recipients. The return of title IV funds calculation would be performed for those students. Any funds required to be disbursed or returned would then be processed. Anticipated Completion Date: February 28, 2024

Names of Responsible Individuals: Brandon Rhone, Analyst, Financial Aid Systems, Chad Wick, Director Financial Aid, and Mark Hergan, VP Enrollment Management Corrective Action: The Financial Aid office made several staffing changes in 2022-2023. The loan coordinator left the institution. Newly hired staff were not properly trained, resulting in the failure to carry out loan notification as required. The VP of Enrollment created a process, implemented in the Spring of 2023, that automated the student loan disbursement notifications with-in the required 30 days of student accounts transmitting their loans. Anticipated Completion Date: February 28, 2024