Corrective Action Plans

Management is responsible for establishing a comprehensive information security policy to safeguard sensitive data. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Management will continue to implement the remaining compliance requirements into a comprehensive policy.

Federal Direct Loan and Pell disbursement dates per the University's billing system did not agree with the reported dates per the Common Origination Disbursement (COD) records. Additionally, Pell award amount did not agree between the students' file and COD records. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Pell and Direct Loan origination records and disbursement records are submitted to the Common Origination Disbursement (COD) either same business day, or next business day. Formal reconciliation process is now completed every month in order to verify disbursement dates and amounts in COD.

Enrollment information was not submitted accurately or within the required timeframe by the University. Personnel Responsible for Corrective Action: Tonya Mourning, Chief Financial Officer, and Mike Pepple, Student Financial Services Director. Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2024. Corrective Action Plan: Management has hired a new Student Financial Services Director and is aware of the federal regulations surrounding enrollment information that must be reported to the NSLDS. Given the complexity of the reporting, management has established additional policies and procedures to address the errors related to enrollment reporting to the NSLDS in a timely and accurate manner.

Pacific understands finding #2023-002 and we agree that the University will enhance its internal controls to ensure all Pell disbursements are reported to COD within 15 days from the initial disbursement. Finding #2023-001 Action: The University notes that in the fall of 2022, there were students whose Pell Grant disbursements were not reported within the 15-day requirement to the Common Origination and Disbursement (COD)system. A Banner system issue allowed the origination of the Pell Grant to be sent to COD, however the disbursements were not. There was no indication this was occurring. To prevent future instances of late Pell Grant reporting, we will take the following action, effective February 6, 2024: • Adding an internal reconciliation component to the 10 day Pell Grant processing reminder • Reconciliation will be completed by the Assistant Director of Financial Aid, Operations of Analytics • Reconciliation will be reviewed and approved by Senior Assistant Director of Financial Aid, Operations and Analytics or Director of Financial Aid, Operations and Analytics Person(s) responsible: Aquila Galgon | Assistant Vice President of Financial Aid and Enrollment Strategy

Finding Number: 2023-006 Condition: Of the 9 students selected for enrollment reporting testing, the Seminary did not properly update student enrollment Information for 1 student in a timely manner. Planned Corrective Action: For students who finish their degree in December, they are reported as "withdrawn" as there is no option to confer in December (institutional policy). The student status is updated to "graduated" and reported to Clearinghouse in May when students are conferred. Contact person responsible for corrective action: Vince McGlothin-Eller, Registrar Anticipated Completion Date: 05/31/2024

Finding Number: 2023-005 Condition: During our review of internal controls and testing procedures, it was noted that no reconciliations could be provided. In addition, the Seminary does not have a quality assurance system in place. Planned Corrective Action: Within 1-2 weeks of each month's end, the Financial Aid Director requests a report from COD (US Department of Education Common Origination & Disbursement) for Direct Loans disbursed that month. That report is retrieved through EDConnect and reviewed. Financial Aid Director generates a report from Jenzabar Financial Aid system of Direct Loans disbursed for that month. The Financial Aid Director also retrieves a report of Direct Loans applied to students' accounts for that month from Business Office Senior Accountant. These three reports are then compared and reconciled for each month. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: Beginning 10/1/2023 (after first month of disbursement)

Finding Number: 2023-004 Condition: The Seminary did not maintain appropriate documentation to substantiate the allowable charges on the student's ledger account to identity whether credit balances were created and required additional documentation from the student to hold the credit balance Planned Corrective Action: Beginning with the Fall 2023 term, Title IV credit balances are no longer held past the 14 days with authorization from the student. The Financial Aid Director implemented a new policy where students cannot request that these funds are retained beyond 14 days. There is a shared list where the Business Office enters the date that the students’ credit balance was released to verify that process happens within 14 days. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/20/2023 (first day of Fall disbursement)

Finding Number: 2023-002 Condition: Of the 19 students who received disbursements selected for testing, the Seminary did not notify any of the students or parents, as applicable, that received direct federal loans within the required 30 days. Planned Corrective Action: Directly after a students’ Direct Loan is disbursed, Financial Aid Director manually sends the loan disbursement notification email to the student (through the Jenzabar financial aid system), which specifies the amount that they borrowed for the term and the right to cancel the loan within 14 days by emailing the Financial Aid Office. This email is recorded in the Jenzabar Financial Aid system. The Financial Aid Director also created a spreadsheet to track Direct Loan disbursements and notifications each term. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/20/2023 (first day of Fall disbursement)

Finding Number: 2023-007 Condition: The Seminary did not identify or provide the appropriate notification to a student that was not meeting the Seminary's policy on satisfactory academic progress (SAP). Planned Corrective Action: Satisfactory academic progress is now being monitored more carefully. The Satisfactory academic progress report is run out of the student financial aid system. The internally generated report is reviewed by the Registrar and Financial Aid Director to confirm that student satisfactory academic progress statuses are correct. Once the appropriate status is confirmed, the Financial Aid Director will document students who are not in compliance with the institution’s policy and provide notifications to each student through email. The emails are recorded in the students' Jenzabar financial aid account. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 06/01/2024

Finding Number: 2023-003 Condition: The Seminary did not have controls in place to identify and document the students who have withdrawn and the applicability of performing a return of Title IV funds. Planned Corrective Action: Financial Aid Director has established a procedure to ensure that R2T4 calculations are completed and any funds due to be returned are sent back to the Department of Education within 45 days of the date of the student's withdrawal. The Financial Aid Director created a listing to track all student withdrawals (including details of withdrawal). The Registrar sends an email to the Financial Aid Director notifying when a student has withdrawn from the institution, which gets entered onto the list. The Financial Aid Director set up the Department of Education's R2T4 calculator for the 2023-2024 academic year. R2T4 calculations are completed for any student withdrawn and if necessary, funds are returned to the Department of Education. Contact person responsible for corrective action: Ashley Schreiner, Director of Financial Aid Anticipated Completion Date: 09/05/2023 (beginning of Fall 2023 term)

06/30/2023 Corrective Action Plan Reference Number: 2023-001 Program Information: Student Financial Assistance Cluster – Federal Direct Loan Program, Federal Pell Grant Program Contact Person: Donna Lane Anticipated Completion: 08/30/2024 Fiscal year in which finding occurred: 2023 Condition Certain students with enrollment changes were not timely transmitted to National Student Loan Data System (“NSLDS’). Management View Management recognizes the importance of reporting enrollment status changes in a timely manner for lenders and servicers of student loans to determine in-school status, deferments, grace periods, and repayment schedules, as well as the federal government’s payment of interest subsidies. Corrective Action The University has taken the following steps to improve the accuracy and timeliness of enrollment reporting with respect to federal requirements: • In addition to the National Student Clearinghouse’s implementation of new password reset requirements, the University will verify the staff representatives on the NSC FTP-site communication list are current. The NSC Enrollment Reporting procedures have been updated to include the FTP communication list and the steps to add or remove members if there are staff changes in the future. • For students who initiate a withdrawal prior to the end of the spring term, the Registrar’s Office will maintain a list to submit manual updates after the final spring enrollment file has been processed. This will ensure timely reporting of the withdrawal without overwriting the spring enrollment submission. • Summer withdrawals will now be reported directly to NSC at the time of withdrawal, ensuring timely and accurate reporting. The Registrar's Office will submit a manual enrollment status change to NSC.

ALLOWABILITY AND ELIGIBILITY Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658 As indicated in the Condition section of the finding, although the documentation related to safety considerations at child care institutions was not initially maintained in the official licensing files for 10 of the 40 cases tested for eligibility, the documentation was eventually provided to the auditors for eight of those 10 cases. For one of the remaining two cases, the child care institution is an out-of-state institution that is no longer in business. For the other case, the child care institution provided documentation, but the documentation did not include the dates of the institution’s safety checks. In an effort to enhance internal controls over the safety considerations at child care institutions, the West Virginia Department of Health and Human Resources, Bureau for Social Services (BSS), is continuing to analyze the condition that led to this finding and is considering a number of steps, including but not limited to the following as an immediate plan of action: • Transmit a copy of 2 CFR 1356.30(f) to all licensing personnel, supervisors, and other applicable staff within the BSS and oblige them to acknowledge that they have read and understand the requirements referenced therein. • Implement a formalized policy and develop written procedures for ensuring the licensing files for child care institutions contain documentation which verifies that safety considerations with respect to the staff of the institutions have been addressed. • Develop overall standards for the maintenance of documentation within licensing files (e.g., a consistent naming convention for the documents, which would improve internal tracking and ensure that requests from independent auditors are addressed efficiently and fully; personnel who have read-only access to documents versus those who can add, replace, and delete documents; record retention requirements; etc.). • Establish a formalized process for monitoring. Such a process would include a strategy for conducting internal reviews of all licensing files on a recurring basis, reporting the results of those reviews to appropriate officials internal and external to the DHHR, following up with those officials as may be necessary, and documenting the overall results accordingly. For example, if the results of a monitoring review indicated noncompliance [or potential noncompliance] on the part of a child care institution, the BSS would inform the institution, request a copy of the institution’s written policies and procedures regarding safety considerations, discuss it with the institution, and provide technical assistance to the maximum extent practicable. Once the BSS drafts the aforementioned policies and procedures and related monitoring process, or otherwise enhances their internal controls over the safety considerations at child care institutions, the BSS will discuss the matter with their regular programmatic contacts at the U.S. Department of Health and Human Services, Administration for Children and Families, and will ask the ACF if the BSS’s planned controls are aligned with the ACF’s universal expectations surrounding 2 CFR 1356.30(f).

ALLOWABILITY AND SPECIAL TESTS AND PROVISIONS – PAYMENT RATE SETTING AND APPLICATION Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658 The West Virginia Department of Health and Human Resources, Bureau for Social Services (BSS), will address the underpayment in question, which was $268.84. The BSS will also revise its training program for child welfare workers to include information regarding demand payments and pro-rating stays in foster care. To accompany the training, the BSS will also develop a desk guide for all child welfare workers and related staff, which will indicate the common monthly rates and pro-rated daily rates along with a contact person to assist with questions concerning any uncommon rates and other pertinent matters.

INFORMATION TECHNOLOGY GENERAL CONTROLS – WVPATH Department of Health and Human Resources (DHHR) Assistance Listing Number 93.658, 93.659 The DHHR, Office of Management Information Services (OMIS), analyzed this finding and hereby offers more details into the condition and cause of the finding. The information technology system in question is named WVPATH, which stands for, “West Virginia People’s Access to Help.” WVPATH is a comprehensive social services/child welfare information system, allowing employees to more efficiently track and view data, streamline services, and ultimately improve the manner by which the State determines eligibility for programs and provides for the delivery of services. With respect to the Foster Care and Adoption programs, the WVPATH system replaced the “Family and Children’s Tracking System” (FACTS). The DHHR transitioned from FACTS to WVPATH in January 2023, which was approximately six months into fiscal year 2023. Fieldwork for the information technology portion of the West Virginia Single Audit began in June 2023. During fieldwork, the auditors inquired about the information technology general controls (ITGCs) within the WVPATH system. In particular, the auditors requested a description of the controls along with a copy of the policies, procedures, system generated listings, screenprints, and other documentation related to information security and access administration, change management, and backup recovery and restoration. Although the OMIS is of the opinion that the State of West Virginia indeed implemented all logical access and change management controls to support effective ITGCs over the WVPATH system, the OMIS did not address the auditor’s request in a timely manner during fieldwork. Therefore, the auditors were unable to determine whether the controls were designed sufficiently, nor were they able to conduct the requisite testing to confirm that the controls were in place and operating effectively during the applicable months of the audit period.   Upon receiving this finding, the OMIS conferred with the State’s third-party software vendor for the WVPATH system; prepared a description of controls; collected the documentation related to information security and access administration, change management, and backup recovery and restoration within the WVPATH system; and submitted the description of controls and related documentation to the auditors. On February 14, 2024, a meeting was held between the auditors, the OMIS, the third-party software vendor, and one of the audit coordinators from the DHHR central finance level. The purpose of the meeting was to discuss this finding and determine whether the documentation collected by the OMIS after fieldwork would have averted the finding in the first place. During the meeting, the auditors indicated that the description of controls is very detailed and appears to support the OMIS’s assertion that the controls are designed sufficiently. However, since the documentation was submitted to the auditors after fieldwork was complete, there was not enough time for the auditors to conduct the requisite testing to determine whether the processes and controls were in place and operating effectively during the applicable months of the audit period. In terms of a corrective action plan for this finding, the OMIS now has a greater understanding of the auditor’s objectives and procedures surrounding ITGCs. During fieldwork for the [forthcoming] West Virginia Single Audit for the year ended June 30, 2024, when the auditors are ready to test the required logical access and change management controls that are required to be in place to support effective ITGCs for the WVPATH system, the OMIS will undoubtedly be prepared to provide the auditors with a description of the controls along with a copy of all documentation related to information security and access administration, change management, and backup recovery and restoration within the WVPATH system.

INTERNAL CONTROLS OVER SPECIAL TESTS AND PROVISIONS – ENROLLMENT REPORTING Bluefield State University, Blueridge Community and Technical College, Concord University, Fairmont State University, Marshall University, Mountwest Community and Technical College, New River Community and Technical College, Pierpont Community and Technical College, Shepherd University, West Liberty University, West Virginia Northern Community College, West Virginia State University, West Virginia University, and West Virginia University at Parkersburg Assistance Listing Number 84.063, 84.268 Bluefield State University (BSU) response Effective February 2024, BSU will review the final enrollment report and approvals will be signed off to submit the report to NSC, the third party will consistently retain a copy within our institution. BSU will retain the record count reconciliation between the final enrollment report, text file, and the number of files received by the NSC, including documentation on how any rejected records were addressed. BSU will retain the details of the validation of the student’s information included in the report for accuracy. BSU will consistently retain the NSC automated emails used as a quality checklist regarding due dates, and receipt of the text files by the NSC. The availability and completion of the Error Resolution Report, as well as the confirmation of certification and processing by the NSC report, will all be retained. Blueridge Community and Technical College (BRCTC) response BRCTC asserts that the Enrollment Reporting process is accurate and reviewed in a timely manner; BRCTC further asserts that the emails from the National Student Clearinghouse are reviewed. As a result of this finding, BRCTC will expand its internal control to include documentation of reviews internally and externally with the NSC. This update to the internal control process was implemented in February 2024. Concord University (CU) response Effective February 2024, the internal controls at CU over the review and approval of the enrollment report sent to the National Student Clearinghouse (NSC) have been updated to include the following control measures in addition to the current controls on file: 1. CU has contacted NSC to begin generating the email response for the receipt of the .txt file when submitting it to the NSC FTP portal. This email notification will be kept on file with the other report documentation. 2. CU has implemented a new checklist sheet to accompany the report and its documentation to provide a clear and organized outline of required documents and to ensure these requirements are provided. This sheet will be part of the Spot Check Letter that is included in the current control method and signed off on by two members of the Registrar’s Office staff. 3. CU has also included in this new checklist a space to document the number of student files submitted to NSC and the number of files submitted to NSLDS as noted by NSC. The printout of this notation provided by NSC will also serve as documentation attached to the report. Fairmont State University (FSU) response Effective February 2024, FSU will retain a screen shot of the record count received by the NSC and will document any rejected records and what the plan is to address the rejected records. FSU will review a portion of the enrollment records being submitted before the submission is uploaded to NSC. This review will include detailed documentation, for a select few, of how we validated the student’s enrollment status. FSU will keep a spreadsheet of the students that are validated and the Banner screens that are used to do so.   Marshall University (MU) response Effective February 2024, MU will document that a record count reconciliation has been completed between the enrollment submission file and the number of files received by the NSC. MU will document and retain how any rejected records were addressed. MU will also document and retain records of the spot check validation for accuracy of student information included in the enrollment submission files. Mountwest Community and Technical College (MCTC) response Effective February 2024, a record count reconciliation between the final enrollment report and the number of files received by the National Student Clearinghouse (NSC) will be completed. MCTC will have the NSC query historical data and have it provided in Excel format. This will be a new source of data that will be collected and retained. This file will be generated after every rejection error report that is returned to the NSC. Each file will be saved, and a copy will be sent to the Registrar’s Office. Transmission history can also be saved by table, that can be exported to Excel. These files will also be saved, and a copy sent to the Registrar’s Office. For validation of student information, MCTC will being the process to collect data for the NSC submission first begin in audit mode. This will allow for review of the data to make any corrections that appear in the first stage of the report. Next, a second row of audits processed by the Associate Registrar will be conducted and confirm the data integrity. After this is complete, a copy of the final submission will be sent to the Registrar for final review and authorization. When approval is returned to the Associate Registrar, the data will be uploaded to the NSC. New River Community and Technical College (NRCTC) response Effective August 2024, the Registrar's office will run a random selection of 20 students from NSLDS to ensure students are correct in the clearinghouse, which will be done at least 50 days out from the time students were initially reported. The Registrar’s office will keep documentation of the sampled students. The Registrar’s office will keep records of how many files were accepted and how many were rejected. The Registrar’s office will provide documentation of validation of student information included in the enrollment report and retain emails by providing a file specially for NSC enrollment reporting emails received and sent regarding enrollment reporting. Emails to be retained are error resolution and confirmation of certification and processing by the NSC. The Registrar’s office will also create a checklist to follow and use as documentation to ensure all steps throughout the process are completed and checked off the list. Pierpont Community and Technical College (PCTC) response Effective February 2024, PCTC will complete the review of the file before it is submitted, not after it’s submitted. The Associate Registrar will pull the report prior to the due date to give those in the review process ample time to review the files before the Associate Registrar submits the document to the NSC. PCTC will keep track of the due date of submission, the date the text file was sent to the NSC, the date the error resolution report was received, the date it was sent back, and the date the report was certified by the NSC. A new tab in the worksheet in Teams has been created that will be completed each time an enrollment verification is submitted to the NSC. PCTC will note the actual enrollment count as of the time of the NSC submission, the enrollment count on the TXT file, the number of files received by the NSC, and the number of rejected files. This is to verify that all of the files intended to be submitted to the NSC were actually received by the NSC and processed. This information will be kept on each spreadsheet used to verify the information sent to the NSC. Shepherd University (SU) response Effective February 2024, SU will add a checklist to the existing reporting and retention structure that had already been established for Clearinghouse data transmission. The checklist will be completed with each transmission, organizing data retention efforts to ensure inclusion of the additional elements required.   West Liberty University (WLU) response To comply with internal control over the review and approval of the enrollment reporting to NSC, WLU will enhance their policies and procedures. The update of these policies and procedures will be effective February 2024 and carry forward into future academic years. WLU will ensure that enrollment reporting policies and procedures are compliant with the US DOE standards and retain evidence of the internal controls. Currently, WLU is reorganizing the processing of enrollment reporting from our IT System Administrator to our Enrollment Services Coordinator. This employee will add to the current policy a process by which a record count reconciliation will happen between the final enrollment report text file and the number of files received by NSC. There will also be documentation kept showing how many rejected records were addressed with each report. Proper documentation will also kept of a final review and approval signoff to submit the enrollment report to NSC. Lastly, WLU will create an email specific to enrollment reporting where all communication from NSC will be stored for auditing and record keeping purposes. West Virginia Northern Community College (WVNCC) response Effective February 2024, the enrollment reporting to the Clearinghouse (NSC) is being moved from the Registrar/Records office to the Institutional Research (PIER office). All reports including determination of reporting intervals per Clearinghouse and SFA guidelines, will be scheduled by the IR office with the Clearinghouse. The following items will be retained to match internal controls for each file sent to the Clearinghouse: 1) Retain internal emails or approval document regarding review and approval from two persons for file prior to sending to NSC 2) Retain verification of count of student record in file matching student enrollment at that time 3) Retain verification of record count with records received by NSC 4) Retain a spot check of students (approx. 8-10) from the file which were tested for accuracy including printout of where this was matched (usually SFAREGS time status page is printed) 5) Retain NSC Error Report for each file prior to resolution and document of resolution 6) Retain reminder email from NSC that the submission file is due 7) Retain initial txt file receipt email from NSC 8) Retain NSC posted error resolution report notification email 9) Retain NSC Completed Error Resolution report notification email 10) Retain NSC final processing email The following information for each file will also need maintained (this information is usually obtained from the NSC reporting page under the enrollment reporting link for approximately an 18 month time frame, header records on the files also show file generation date and term date information for the students reported). 1) Scheduled transmission date 2) File certification date 3) NSC received date 4) NSC processed date 5) Academic term the file is sent for 6) Submission type of the file (first of term, subsequent of term, graduate only, etc.) West Virginia State University (WVSU) response WVSU utilizes the National Student Clearinghouse (NSC) to update student’s enrollment and its effects on student’s direct loan and Pell statuses. Thorough edit checks of student data for each semester will be produced by IT on a regular basis. The Office of the Registrar, in coordination with Admissions, Dual Enrollment, and other contributors of student data, will make sure these errors are corrected. Special focus will be placed on resolving these errors before each enrollment file is produced. (initial data integrity, first check). On or around the 25th of each month, IT will produce the NSC enrollment file. Each time the file is produced, the file will be sent to the Registrar for review to ensure accuracy of the data being pulled from Banner. Registrar sends approval for upload to NSC. Emails from NSC, IT, and files with student checks to be retained. (process integrity, second check) The file will be uploaded to the NSC by IT, ensuring NSC received the appropriate number of records. The data will then be reviewed and any discrepancies in the data, when compared with past data, will be resolved in a timely manner. The NSC error report will be reviewed and any errors corrected. The NSC process makes sure these errors are resolved before the data is reported to the NSLDS, it is the responsibility of the Registrar to make sure these are resolved with accurate data. Emails from NSC, and screenshots of errors will be retained. (data integrity, third check) After resolution of errors, the NSC will perform a final review of data before sending to the NSLDS. This will be reported on the NSLDS Reporting tab of the Enrollment Reporting screen in the NSC website. If data is satisfactory, the submission will be marked with “Congrats. No Errors!” by the originator clearinghouse. The NSC sends emails whenever these items are updated. It is the responsibility of the Registrar to review and resolve any errors in a timely manner. Emails from NSC and screenshot of NSLDS reporting dashboard to be retained. (data integrity, fourth check) The enrollment data is then submitted to the NSLDS. After NSLDS reviews the data, any errors will be reported back through the NSC in the same manner as NSC errors. Resolution of these errors is of special importance and will be given top priority. The NSC sends emails whenever these items are updated. It is the responsibility of the registrar to review and resolve any errors in a timely manner. Emails from NSC and any error documentation to be retained. (data integrity, fifth check). These policies and procedures will be implemented in August 2024. West Virginia University (WVU) response WVU’s Registrar’s office reviews rejected records and takes appropriate action to clear the rejections. Many of these rejections require additional information from students, therefore resolution is based on student discretion in providing documentation. Effective February 2024, WVU will ensure that documentation of the submission record count and rejection follow up is maintained. West Virginia University at Parkersburg (WVU-P) response Effective February 2024, WVU-P will reconcile the record count of enrollment records processed by taking the following actions: 1. Highlighting the record count at the end of the Banner-generated enrollment report file as part of the spot-checking review process. 2. Screenshotting the number of files received by NSC once they acknowledge that the file has been received. 3. Retaining documentation to show that if for some reason the file count does not match, research was done to locate the reason for the discrepancy, and the discrepancy was either resolved or WVU-P is able to document why it could not be resolved. Records and Financial Aid are working together now to develop procedures to properly document the error resolution process. WVU-P will have this process in place by April 2024, in time for the new process to be fully implemented beginning with the Summer 2024 term. WVU-P will retain all documentation, including all emails sent by NSC throughout each enrollment reporting process, within a folder in a secure drive. The name of the folder will be the date that the enrollment report was sent to NSC.

INTERNAL CONTROLS OVER FINANCIAL REPORTING Pierpont Community and Technical College (PCTC) Assistance Listing Number 84.063, 84.268 Beginning October 2022, PCTC has performed the updated monthly reconciliation process that was originally to take place beginning July 1, 2022. Due to the loss of the Information Systems Specialist (ISS), PCTC failed to begin on the intended date. The DLSAS reports from COD are downloaded by the 10th of each month, as before, by the ISS. The reports are provided to the Assistant Director of Financial Aid (Asst.) and then reconciled to both Banner paid and Common Origination and Disbursement (COD). The Asst. takes screen captures of both Banner and COD for a monthly reconciliation of the Federal Pell Grant and DL programs. Screen captures are printed, and comparisons are made by the Asst. All necessary adjustments are performed to student accounts by the Asst. or Director of Financial Aid (Director) until balanced. Reports verifying reconciliation are then completed, initialed, and saved by the Asst. and then reviewed and signed by the Director for completion and accuracy. PCTC will maintain the documentation of the DLSAS statements each month and the reconciliation report along with evidence of said review. The completed reconciliation information files are in our shared drive. This process has been in place, ongoing and has been effectively followed since October 2022.

SPECIAL TESTS AND PROVISIONS – PERKINS LOAN RECORDKEEPING AND RECORD RETENTION Concord University, Marshall University, Shepherd University, West Liberty University, West Virginia School of Osteopathic Medicine, and West Virginia University Assistance Listing Number 84.038 Concord University (CU) response Due to changes in personnel, CU did not follow this regulation. CU will review ECSI’s report, specifically looking for instances of noncompliance and internal control breaches. This will be documented annually and will be effective August 2024. Marshall University (MU) response MU has regularly monitored the services provided by ECSI for accuracy and completeness throughout a 30-year relationship without significant issues. Additionally, during fiscal year 2023, MU worked closely with ECSI on the Department of Education’s government assignment of 837 Perkins loans going back as far as 1978. This process clearly involved several compliance requirements of this program and was completed with no compliance problems encountered. MU will document the review of ECSI’s annual audit going forward. Shepherd University (SU) response By April 2024, SU will develop and maintain a checklist that will be periodically reviewed and signed off related to this finding, specifically: Annually, SU will pull SOC reports along with any compliance audits for review of findings or areas of interest and will assess and determine any factors that may need further investigation or mitigation from SU. West Liberty University (WLU) response Effective February 2024, WLU’s CFO, Controller and Student Accounts Manager together will meet and review the most recent Title IV compliance audit. The meeting will be set using emails. Minutes and notes will be taken regarding items reviewed and conclusions reached and will retain documentation and all other relevant documentation will be retained. Any issues that arise will be dealt with accordingly. West Virginia School of Osteopathic Medicine (WVSOM) response Adequate due diligence was not performed to ensure that the third-party services, Educational Computer Systems, Inc. (ECSI) were following the requirements for the functions that they are performing for WVSOM. The third-party services Title IV compliance audit was obtained but was not signed off on as reviewed. A new procedure will be written with the following steps: 1) Accountant Senior in the Cashiers office will request the “Examination Report on Compliance with Title IV Programs” and the System and Organization Controls for Service Organizations: Controls Relevant to Security (SOC 2). The Accountant Senior will review the reports for compliance and sign off. 2) Accountant Senior will forward the reports to the Director of Finance. The reports will be reviewed for compliance and signed. 3) The Director of Finance will forward it to the Director of Accounting for submission with the audit. The new procedure will provide two reviews and sign-offs and are effective January 2024. West Virginia University (WVU) response WVU’s Student Financials Services (SFS) department receives the 3rd Party Servicer compliance reports annually and reviews these reports once received. WVU will maintain detailed meeting minutes to document the review of 3rd Party Servicer reports moving forward. The review of the report available for fiscal year 2024 was conducted on December 19, 2023 between members of Compliance and Training (CT) and Revenue Management (RM) teams. In this meeting, the following 3rd Party Servicer reports were discussed; report on controls at a service organization relevant to user entities’ internal control over financial reporting, SOC 2 report and examination report on compliance with Title IV programs. It was noted there were no findings in the reports. Regarding MPN’s, deferments and cancellations for Perkins loans, members of SFS are pursuing several areas of remediation to resolve the fiscal year 2023 finding. SFS personnel will review all open Perkins loans and inventory files to consolidate into one central location. All files will be reviewed for paper MPN’s, deferment and cancellations request and an inventory list will be attached to a central location for all Perkins records. Additionally, WVU is in the process of exploring liquidation of all Perkins loans currently held by the school. While SFS is committed to resolving the current issues regarding Perkins Recordkeeping, it should be noted that this commitment must be balanced with staff’s requirements to process student aid for current students that has been delayed numerous times due to FAFSA simplification delays.

SPECIAL TESTS AND PROVISIONS – USING A SERVICER TO DELIVER TITLE IV CREDIT BALANCES TO A CARD OR OTHER ACCESS DEVICE Bluefield State University, Blueridge Community & Technical College, Concord University, Mountwest Community and Technical College, Shepherd University, West Virginia Northern Community College, and West Virginia University at Parkersburg Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364 Bluefield State University (BSU) response BSU will submit the URL of their contract with their third-party servicer and cost information to the U.S. Department of Education for their publication in the Cash Management Contracts Database by Friday, February 23, 2024. BSU will also implement a detailed due diligence review over the fees assessed by the third-party servicer of Title IV credit balances. Blueridge Community & Technical College (BRCTC) response We acknowledge that BRCTC did not have internal controls in place to review the contract with our third-party servicer of Title IV credit balances or obtain and review the third-party servicer’s Title IV compliance audit to ensure compliance with federal regulations. By February 2024, documents will be requested and an annual due diligence review will be performed and documented of the third-party servicer contract and compliance audit as well as review of fees assessed by the third-party servicer. Concord University (CU) response CU agrees with this finding and due to changes in personnel, this regulation was not followed. CU will review and document the review of the Cash Management Database annually to ensure the link is posted. CU will review and document the review of other financial institutions charges compared against BankMobile’s fees annually. CU will annually review the servicer’s SOC report. CU will review BankMobile’s report, specifically looking for instances of noncompliance and internal control breaches. This will be documented annually. Mountwest Community and Technical College (MCTC) response Effective February 2024, MCTC will implement a review process to be conducted on an annual or monthly basis, as applicable, of all accounts opened with the Servicer during the specified timeframe. The "Activation & Preferences Report" available to management through the Servicers Administrator portal will be used to provide the data for review by management. The review process will consist of the following: • A request made of the servicer to provide a report of accounts opened with date/time stamp of consent to opening. Frequency: Monthly • Review of "Activation & Preferences Report" validated against Servicer "Accounts Opened" report. Frequency: Monthly • Generate a follow-up email to applicable students confirming the opening of the Servicer Account which will include an attachment of the Servicer "Terms and Conditions" and "Fee Schedules". Frequency: Monthly • Review the Servicers' Client Contract and Profile site for accuracy and completeness of information. Frequency: Annually • Review the Servicers' System and Organization Controls (SOC) and Compliance audits. Frequency: Annually • Management will incorporate as part of its "Due Diligence and Attestation" copies of comparable banking institution fee schedules that are date/time stamped to serve as evidence of review. Shepherd University (SU) response By April 2024, SU will develop and maintain a checklist that will be periodically reviewed and signed off related to this finding, specifically: Annually, SU will be submitting the URL to the Department of Education related to the contracts between SU and BankMobile, reviewing compliance audits and SOC reports for BankMobile, recording areas of risk, and noting ways to mitigate the potential risk moving forward. West Virginia Northern Community College (WVNCC) response Beginning June 2024, during the annual review meeting between WVNCC and BankMobile (the servicer that delivers Title IV credit balances to students), WVNCC will obtain a copy of the BankMobile compliance audit. This will be kept on file within the Business Office for reference if needed. In addition, the budget committee will review annual the fees charged by BankMobile and attempt to compare them to other providers of similar services. West Virginia University at Parkersburg (WVU-P) response WVU-P has submitted a URL to the US Department of Education of our contract and cost information with our third-party servicer. This submission should correct this portion of the finding although it was done after the end of the fiscal year under audit but serves to correct the finding in subsequent periods. WVU-P will ensure compliance with the remaining items noted by creating a written internal control policy requiring the following: • Verification of the required submission of the third-party contract with the Department of Education. • Documentation of a due diligence review of the fees assessed by the third-party servicer. • Obtain a copy of the annual compliance examination of the Title IV Programs. The 2022 report dated June 29, 2023, was received and reviewed by us for compliance with eligibility, systems, and internal controls, disbursements, Return of Title IV funds, and administrative requirements. • Obtain a list of students whose refunds were disbursed by the third-party vendor and cross-reference it with a list of the students processed and sent to the third-party vendor by WVU-P. For those students who elected to open a checking account, WVU-P will review supporting documentation to indicate that the student gave proper consent. These policies and procedures will be effective February 2024.

SPECIAL TESTS AND PROVISIONS – RETURN OF TITLE IV FUNDS Blueridge Community and Technical College, Bluefield State University, Fairmont State University, Mountwest Community & Technical College, Pierpont Community and Technical College, and West Virginia Northern Community College Assistance Listing Number 84.007, 84.033, 84.063, 84.268 Blueridge Community and Technical College (BRCTC) response BRCTC maintains a review procedure implemented in December 2023 over the entire Return of Title IV process; after this review, BRCTC will add a secondary review and sign off of those students whose aid does not have to be returned due to being outside the return window. Bluefield State University (BSU) response Effective February 2024, internal controls are in place to perform the Return of Title IV withdrawal and calculation ensuring records comply and that Return of Title IV Refunds are within the required time frame of 45 days. Controls include the review of “Permit to Withdraw” forms to ensure they are completed with all signatures of offices involved and the sign off of Return of Title IV calculations. All reviews will occur within the time frame of 45 days by the Financial Aid Director along with Business Office and Accounting. On February 8, 2024, the Director of Financial Aid spoke with the Registrar and the FA Counselors in separate meetings regarding the late submission of withdrawal forms and performing the Return of Title IV calculations. The Registrar understands they must submit the completed withdrawal forms to the Financial Aid office the same day they are completed by her office. When the forms are received by Financial Aid, a Return of Title IV will be completed within the same week of receipt and sent to the Business Office, if a Return of Title IV Aid is required. The Business Office will then review the calculations and perform the necessary repayment of Title IV Aid to the Department of Ed, utilizing the refund process through G5 within the required 45-day timeline. All adjustments to the students account will be made with in the same time frame.   Fairmont State University (FSU) response FSU has been identified as an institution that does not have adequate internal controls in place over the return of Title IV funds to prevent noncompliance. FSU has implemented the following Return of Title IV controls. Step by Step-Initial Review: 1. FSU (Information Systems Technician) performs all Return of Title IV calculations through FAA Access to CPS on-line. 2. In Banner, the funds are unapplied to the student’s account according to the Return of Title IV calculation from FAA Access. 3. Return completed Title IV Returns spreadsheet to the Accounting Assistant II that sent them to you with a ‘y’ in the column marked Aid Returned and the dollar amounts of any aid that was returned, and if a letter was mailed to the student and the dollar amount the student is responsible for paying. 4. In Banner comments are added to RHACOMM which include the date of withdraw(s), the type of funds that were returned and the amount of each fund that was returned. 5. If the student has to return Pell Grant (section 10 of the Title IV worksheet)- must send a letter then student has 45 days. Follow up according to federal regulations. 6. If there is a post withdraw disbursement, a letter is sent to the student. Follow up according to federal regulations. 7. FSU only completes the Return of Title IV calculation for students who have withdrawn outside of the withdraw window upon request. Secondary Review: FSU (Financial Aid Counselor) performs a second review of the Return of Title IV calculations through FAA Access to CPA on-line. This individual verified the data for the calculation has been entered correctly, the adjustments to the Banner system are accurate, and signs off on the Return to Title IV calculation worksheet. FSU has the following controls in place: Who performs the control? Finance Program Manager and Information Systems Technician. What are the reviewer’s qualifications? 3+ years’ experience. When or how often is the control performed? Weekly. What does the reviewer evaluate? Verifies the data for the calculation has been entered correctly, and the adjustments to the Banner system are accurate. What precision is encompassed? (How granular is the review? What are the criteria for investigation? What is the objective of the review?) By student. Additional investigation is needed when reviewer cannot produce the same results from the Return to Title IV form. Verify the accuracy of the calculation and to ensure the data being used for recalculation is accurate. What actions are taken or result? Redoing the recalculation worksheet after verifying the data from the system. Mountwest Career & Technical College (MCTC) response MCTC maintains email communication regarding the completion of Unofficial Return of Title IV Withdrawal Calculations each semester indicating timeliness of calculations. Sampling is done to check calculations and that will be made available in future audits, effective February 2024. MCTC will maintain the SFRWDRL reports for all withdrawals (both official and unofficial) run in “update” mode with notations to indicate timeliness, and to indicate that touch points along the calculation have been reviewed such as checking start and end dates in STVTERM and break days in SOATBRK as well as percentage calculated comparing Banner percentages to manually calculated percentages. Sampling of calculations will be compared to manual calculations using USDE supplied manual Return to Title IV worksheets to ensure that the Banner calculation of returns aligns with the manual calculation. Pierpont Community and Technical College (PCTC) response During the prior year’s audit, it was discovered that the prior processer was not completing the Return of Title IV properly. The processer left employment and Return of Title IV procedures were taught to the new processer and Asst. Director. This took place in November 2022. Unfortunately, the processer also did not complete two Return to Title IV before leaving and failed to communicate this information. It was not discovered until after the 45-day window for completion. Upon discovery, the two Return of Title IV were completed and PCTC have since followed the process and have had no additional similar findings. The process is functioning properly which will continue to be followed going forward. West Virginia Northern Community College (WVNCC) response Effective February 2024, for Return to Title IV review and processing in addition to the policies and procedures manual, these additional steps will be taken to maintain internal controls including maintaining email communication regarding the completion of Return of Title IV withdrawal calculations each semester indicating timeliness of calculations. Sampling will be done to check calculations and will be made available in future audits. WVNCC will continue to maintain in the Registrar’s office, the SFRWDRL reports for all withdrawals (both official and unofficial) run in “Update” mode with notations to indicate timeliness, and to indicate the calculations have been reviewed such as checking start and end dates in STVTERM and break days in SOATBRK as well as percentage calculated comparing Banner percentages to manually calculated percentages. The Financial Aid office will maintain a sampling of calculations that are compared to manual calculations using US Dept of Ed supplied manual Return of Title IV Worksheets to ensure that the Banner calculation of returns aligns with the manual calculation. Additionally for the Fall 2024 semester, a manual sampling of calculations will be reviewed to confirm that the calculations for the current award year are matching.

SPECIAL TESTS AND PROVISIONS – SATISFACTORY ACADEMIC PROGRESS Blue Ridge Community and Technical College, Bluefield State University, Fairmont State University, Marshall University, New River Community and Technical College, West Liberty University, West Virginia Northern Community College, West Virginia School of Osteopathic Medicine, and West Virginia University at Parkersburg Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364 Blue Ridge Community and Technical College (BRCTC) response BRCTC agrees with the auditor’s comments that the internal control process regarding the Satisfactory Academic Progress (SAP) Policy can be improved by maintaining documentation of an annual formal review of the SAP policy and its publication on the website, internal policy manuals and the student catalog. Effective January 2024, BRCTC’s website has been updated to appropriately reflect the SAP policy. Bluefield State University (BSU) response Effective January 2024, internal controls are in place to perform the Review of the Standards of Satisfactory Academic Progress Policy to comply with federal regulations 2-CFR 200.303, 34 CFR 668.16 (e) and 34 CFR 668.34. The current SAP policy was reviewed in June of 2023, but a signature was not maintained. The SAP policy will be reviewed annually prior to the new academic year that begins each August. The review will consist of the Director of Financial Aid, Chief Financial Officer and Provost reviewing all aspects of the current policy at first and then maintaining any changes annually along with retaining signatures of the annual review. The policies and procedures will be given a new review date each year to reflect the process.   Fairmont State University (FSU) response Effective January 2024, the following has been placed into the Satisfactory Academic Progress policy and will go into effect in Spring 2024 - Institutional Documentation Retention. Prior to the Satisfactory Academic Progress policy being applied to students at FSU, the Director will be responsible for the following: 1. Download the most current Satisfactory Academic Progress regulations from studentaid.gov. This documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 2. Review, compare, and update the current Satisfactory Academic Progress policy at FSU with the most current federal regulations. The most current version of the policy will be signed off and dated by the Director of Financial Aid & Scholarship. This documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 3. The Director of Financial Aid & Scholarships will provide any updates to the policy to the Information Systems Specialist by email in order for the Banner system to be updated with the updates. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 4. The Information Systems Specialist will update the Banner system in TEST. 5. The updates will be ran in TEST by running the ROPSAPR process for the future fall and future summer terms. 6. The TEST data will be reviewed and evaluated to ensure all policy updates have been captured and the students have been appropriately evaluated according to federal regulations. 7. The Information Systems Specialist will notify the Director of Financial Aid & Scholarships by email the status of the TEST system to determine if additional updates need to be made. 8. If the Director approves the data from the TEST system, they will notify the Information Systems Specialist by email that the updates are ready for production. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 9. Updates will be applied to the production system by the Information Systems Specialist and the ROPSAPR process will be run on all current students for evaluation. 10. The Information Systems Specialist will notify the Director of Financial Aid & Scholarships by email once the process is complete for one final review of the data to ensure all federal regulations are being met and the students have been evaluated accordingly. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. 11. The Director of Financial Aid & Scholarships will sign off on the completed process by email to the Information Systems Specialist. Email documentation will be retained on the M drive under the appropriate aid year file folder for SAP. Marshall University (MU) response MU updated the website in February-March which included a review of SAP Policies and Procedures. MU did not update the Revision Date as there were no updates to Satisfactory Academic Progress federal regulations for the 2023-24 aid year. The policy did not change but was reviewed when updates were made to the website. This policy was updated and also added to the website. Effective February 2024, MU will document and retain all reviews and approvals for compliance with federal regulations. New River Community and Technical College (NRCTC) response NRCTC will continue to review policies and procedures at least once, and sometimes twice a year when the catalog is reviewed. NRCTC will continue doing this review and maintain documentation to ensure compliance with federal regulations. West Liberty University (WLU) response Effective January 2024, to comply with internal control over federal awards, WLU will ensure that SAP policies are compliant with the US DOE standards and retain evidence of the review before the SAP procedures are completed annually. If there are no changes, the policy will be approved to move forward. A signed sheet of the SAP policy approval will be retained in the office and an email of no updates will be sent to others in the Financial Aid Office. If changes are necessary, a financial aid committee would meet to make the appropriate updates. Once the policies and procedures are updated, a signed copy of the update will be retained in the FA Office and an email of the updates will be sent to the Financial Aid Office and communicated to all faculty, staff and students. West Virginia Northern Community College (WVNCC) response Effective December 2023, a new internal control process has been added to validate WVNCC’s processes (including SAP) with any changes to the Dept of Ed regulations, as available for the upcoming school year. WVNCC begins creating the new policy and procedure manual as the new year financial aid setup begins. The Director of Financial Aid will be creating a task force which meets two times per year to review the procedures. As WVNCC’s policy and procedure manual is a live working document, updates will be made as needed with a revision date denoted where applicable. WVNCC had an initial conversation with NASFAA on their policy and procedure information available and has created a sign off form to verify the review of the policy each academic year. This process is being implemented during the 2023-2024, prior to this year, as with the 2022-2023 documents, changes in regulations or college policy changes were made in the policy and procedure manual but may not have had a revision date as it done during the manual creation. This process will be fully implemented for the new 2024-2025 policy and procedure manual as it is being created. The new control will formalize this process, a review of applicable review is in process. West Virginia School of Osteopathic Medicine (WVSOM) response WVSOM did not have adequate internal controls in place surrounding the satisfactory academic policy (SAP) policy. A new SAP policy will be written and published to the public website to include reasonable standards for measuring whether eligible students are maintaining SAP in the educational program in our published SAP policy. The new policy will provide notification to the students of the results of an evaluation that impacts the students’ eligibility for title IV program funds. WVSOM will retain sufficient documentation that the procedures are performed and reviewed by the Financial Aid Director and a second review performed by the Associate Director of Financial Aid. The review will provide two signature sign-offs. West Virginia University at Parkersburg (WVU-P) response Financial Aid employees review all financial aid policies and procedures at minimum once per academic year. The Satisfactory Academic Progress (SAP) policy was reviewed and updated by financial aid staff throughout the spring and was approved by the Executive Vice President in June 2023, the updated SAP policy was forwarded to the President’s office to be filed and posted in the appropriate places, including online. WVU-P agrees that the updated and most recent SAP policy was not posted to the website prior to June 30, 2023. There was a college-wide policy review this spring, and the volume of that caused a delay in the policy’s posting. The resolution for this issue is to complete our policy review process earlier, and ensure if updates are necessary then the Marketing and Communications staff are aware of a deadline prior to June 30 to post the updated policy. WVU-P believes that there is sufficient documentation to show that the review of the SAP policy occurred within the academic year. The policies themselves have footnotes to document that Heather Skidmore reviewed the policies, and then the secondary review completed by Alice Harris before submission to the President. WVU-P will retain all communication that occurs related to future review processes to avoid a repeat finding on this issue.

DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, COVID-19 93.777, 93.778 The DHHR is currently phasing in a new information technology system for determining eligibility, making payments, maintaining documentation, etc. The name of the new system is WVPATH (West Virginia People's Access to Help). The WVPATH system will replace the Family and Children's Tracking System (FACTS) and the Recipient Automated Payment Information Data System (RAPIDS), which are currently referenced in the finding. The WVPATH system will have additional controls and levels of review as compared with the FACTS and RAPIDS systems. Due to the timing of the phase-in process, the DHHR anticipates the finding will be resolved for the year ended June 30, 2024.

On a weekly basis, the Registrar will download the Registration Status Report from the student information system and review the report for accuracy. A copy will be provided to the Director of Financial Aid and the Accounts Receivable Coordinator to ensure all withdrawn students have been communicated in a timely fashion and all R2T4s are processed timely.

On a monthly basis, the Registrar will download the Registration Status report from the student information system and review the report for accuracy to ensure all enrollment changes are captured. Once the review is complete, the information will be uploaded to the National Student Clearinghouse.

Finding 2023-001: Special Test and Provisions: Enrollment Reporting Context/Condition: Of the 40 students selected for enrollment reporting testing, 6 students within the sample were reported to NSLDS outside the maximum 60-day window. Recommendation: The auditor recommended that the University review and update internal controls to ensure student enrollment status in the National Student Loan Data System (NSLDS) is updated in a timely manner to ensure compliance with Federal Requirements. Persons Responsible for Corrective Action: Liz Force, University Registrar & Director of Records; Pam Barrett, Associate Vice President & Director of Financial Aid Planned Corrective Action: Brenau University contracts with the National Student Clearinghouse (NSC) to perform routine enrollment reporting required by Title IV Federal Student Aid regulations. The University's student information system contains a program designed to compile enrollment data for transmission to NSC in accordance with specifications provided by the National Student Loan Data System (NSLDS). We conducted a detailed review of the November 2022 NSLDS Reporting Guide and engaged the University's student information system vendor, who reviewed the current software logic and installed the modifications necessary to become compliant in this area. Anticipated Completion Date: November 7, 2023

Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.038, 84.268, 84.033, 84.007, 84.063, 93.264 Recommendation: We recommend the University evaluate its procedures and policies around reporting Direct Loan disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We disburse aid weekly and we have implemented a plan to review the reported disbursements in COD to ensure they are being reported accurately. Name(s) of the contact person(s) responsible for corrective action: Mark Freed Planned completion date for corrective action plan: June 30, 2023