Corrective Action Plans

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1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. In September 2022, the County issued the Notice of Federal Subaward Information template, which contains the 14 reporting elements requir...
1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. In September 2022, the County issued the Notice of Federal Subaward Information template, which contains the 14 reporting elements required by 2 CFR §200.332(a) that must be provided to subrecipients at the time of the subaward. The County will issue written correspondence reminding departments to complete the Notice of Federal Subaward Information template and provide a completed copy to the subrecipient at the time of the subaward. The County will also remind departments to provide all the required elements from 2 CFR §200.332(a) via letter or amended agreement to existing subrecipients that were not initially provided all the requirements. In the same correspondence, the County will remind departments to monitor their Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) subrecipients, maintain sufficient records of the monitoring, and utilize the Subrecipient Monitoring Guide issued in June 2023. 3. Anticipated implementation date: June 28, 2024
Finding 388361 (2023-002)
Significant Deficiency 2023
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with this finding and recommendation. DPH will ensure to report Federal expenditures in the SEFA under the correct ALN based on Time Studies received. 3. Anticipated implementation date: Mar...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with this finding and recommendation. DPH will ensure to report Federal expenditures in the SEFA under the correct ALN based on Time Studies received. 3. Anticipated implementation date: March 7, 2024
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the sub...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the subaward execution or modification of relevant federal award information and 2) uploads federal subaward information to FFATA within 30 days of the effective date of the subaward execution or modification of relevant federal award information. These notifications will happen for all subawards that meet the threshold for FFATA reporting. DHSP understands that these notifications may precede the full execution of a new contract or subaward. 3. Anticipated implementation date: July 1, 2024
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Center for Health Equity agrees with the finding and recommendation. Moving forward staff will check the SAM exclusions before entering into any contracts and maintain documentation of that verification to...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Center for Health Equity agrees with the finding and recommendation. Moving forward staff will check the SAM exclusions before entering into any contracts and maintain documentation of that verification to provide upon request. 3. Anticipated implementation date: July 1, 2024
Finding 388355 (2023-001)
Significant Deficiency 2023
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with finding and recommendation. Finance will take the following corrective action: • Initiate direct, written communication with the Auditor-Controller to seek precise instructions and guida...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with finding and recommendation. Finance will take the following corrective action: • Initiate direct, written communication with the Auditor-Controller to seek precise instructions and guidance on the inclusion of accruals in our reporting. • Proactively review and document accrual procedures, ensuring alignment with regulatory requirements. • Prospectively include and implement accrual reporting in the Single Audit. • Establish a communication protocol with the Auditor-Controller to address any future uncertainties promptly. Through these measures, DPH aims to address the audit finding, establish clear guidelines for accrual reporting, and ensure compliance with reporting requirements while maintaining transparency and accuracy in our financial reporting practices. 3. Anticipated implementation date: April 1, 2024
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Acute Communicable Disease Control (ACDC) agrees with the finding and recommendation. Before entering into contract, DPH will check for SAM exclusions with date indicating verification before contract exe...
1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Acute Communicable Disease Control (ACDC) agrees with the finding and recommendation. Before entering into contract, DPH will check for SAM exclusions with date indicating verification before contract execution and keep this documentation on file. DPH, Administrative Services Division (ASD) - Procurement agrees with the finding and recommendation. DPH’s Administrative Services Division Manager will email Procurement staff to remind staff/manager to ensure SAM.GOV verification documents are included in all federally funded purchases before finalizing/approving those transactions. 3. Anticipated implementation date: March 11, 2024 and April 30, 2024
Federal Program: COVID-19 - Education Stabilization Fund - Higher Education Emergency Relief Fund - Student and Institutional Aid Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Year: June 30, 2023 Criterion:...
Federal Program: COVID-19 - Education Stabilization Fund - Higher Education Emergency Relief Fund - Student and Institutional Aid Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.425E, 84.425F Federal Award Year: June 30, 2023 Criterion: The U.S. Department of Education (the Department) has issued guidance for the Education Stabilization Funds (ESF) Higher Education Emergency Relief Funds (HEERF) for quarterly reporting for all Sections (a)(1), (a)(2), (a)(3) and (a)(4) that requires that institutions to prepare a report for each quarter for funds that are drawn down and disbursed/spent. The reports are to be posted on the institution’s website within 10 days of the calendar quarter end. Additionally, institutions are required to prepare an annual report and submit to the Department summarizing the uses of the HEERF funds for the calendar year. Condition While all reports in question were submitted on time to the DOE, there was no evidence maintained of timely reporting on the College website for the student or institutional reports for the quarter ending June 30, 2023; or for the annual period ending December 31, 2022. Corrective Action Plan All reports will be resubmitted to the College website in chronological order. Responsible Person Connie Jablonski—Associate Vice President of Finance and Administration Anticipated Completion Date The final report (quarter ended December 2023) was submitted in a timely manner to the Department of Education. The chronological submission of all HEERF related reports to the College website is anticipated to begin in early February. A review will be a part of Thiel’s Audit Process for Fiscal 2023 – 2024.
Federal Program: Student Financial Assistance Cluster - Federal Direct Student Loan Program Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.268 Federal Award Year: June 30, 2023 Criterion: Title IV regulations (34 CFR 685.309b) require t...
Federal Program: Student Financial Assistance Cluster - Federal Direct Student Loan Program Federal Agency: U.S. Department of Education Pass-Through Entity: Not applicable Assistance Listing Number: 84.268 Federal Award Year: June 30, 2023 Criterion: Title IV regulations (34 CFR 685.309b) require that upon receipt of an enrollment report from the Secretary, Institutions must update all information included in the report and return the report to the Secretary; (i) in the manner and format prescribed by the Secretary; and (ii) within the timeframe prescribed by the Secretary. Unless it expects to submit its next updated enrollment report to the Secretary within the next 60 days, an Institution must notify the Secretary within 30 days after the date the Institution discover that: (i) a loan under Title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the Institution and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least a half-time basis for the period for which the loan was intended; or (ii) a student who is enrolled at the Institution and who received a loan under Title IV of the Act has changed his or her permanent address. Condition and Context: For one student out of 25 selected for testing, the College did not notify the NSLDS in a timely matter for a change in enrollment status. Cause and Effect: The College failed to follow its procedures for reporting student status changes. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by schools. If an institution does not review, update, and verify student enrollment statuses, effective dates of the enrollment status, and the anticipated completion dates, then the Title IV student loan records will be inaccurate in NSLDS. Recommendation: The College should implement a process and related to verify with NSLDS that all enrollment status information for all students is updated accurately and timely. Recommendation: The College should implement a process and related to verify with NSLDS that all enrollment status information for all students is updated accurately and timely. Corrective Action Plan The College will continue to work with the NSC Audit Response Team, Office of the Registrar, and Office of Information Technology to resolve the data reporting issues we are currently experiencing. Denise Owens, Student Loan Specialist and Debra Schreiber, Registrar will work together to provide manual data reporting to NSLDS in an accurate and timely manner. Responsible Persons Michelle Work, Director of Financial Aid Denise Owens, Student Loan Specialist Dr. Laura Pickens, Associate Dean for Academic Programs and Records Debra Schreiber, Registrar Anticipated Completion Date This is an ongoing process and will begin immediately.
2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, ...
2023-002 Reporting – Material Weakness View of Responsible Officials Administration agrees with the findings and recommendations. Corrective Action Plan The Office of Monitoring and Compliance (MAC) will provide training to recipients when funds are allocated within the Department. The Policy, Innovation, Planning and Evaluation Branch (PIPE) will communicate with the Office of Fiscal Services and MAC on a semi-annual basis to start the reporting process on December 1 and June 1 of each year to meet the January 31 and July 31 respective deadlines. Additionally, PIPE has identified a dedicated staff member who will spearhead the administration of this grant to ensure that any changes in the reporting requirements as defined in the OIA Cooperative Agreement will be quickly identified and followed. Contact Persons: Ken Kakesako, Director Policy, Innovation, Planning and Evaluation Branch Office of Strategy Innovation and Performance Jacy Yamamoto, Interim Director Office of Monitoring and Compliance Office of the Deputy Superintendent Anticipated Completion Date: June 1, 2024
Reporting – FSRS Failure to accurately and timely report First tier subawards to FSRS results in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will create a procedure to implement timely reporting of the first-tier subawards of $30,000 or more Federal Funding Accountabil...
Reporting – FSRS Failure to accurately and timely report First tier subawards to FSRS results in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will create a procedure to implement timely reporting of the first-tier subawards of $30,000 or more Federal Funding Accountability and Transparency Act (FSRS) no later than the end of the month following the month in which the obligation (indicated by the start date of the new contract) is made. Upon notification of the contract and/or contract modification, the Administrative Officer will submit and update the FFATA-FSRS report until the vacant Administrative Specialist position is filled. Implementation Date: July 1, 2024 Responding Official: John Valera, Administrator and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Reporting FSRS were not timely submitted and/or key data elements did not agree to the source documents. Corrective Action Plan: We will work with AMHD to submit the FSRS report in a timely manner going forward. Implementation Date: July 1, 2024 Responding Official: Janet Ledoux, Administrative Offi...
Reporting FSRS were not timely submitted and/or key data elements did not agree to the source documents. Corrective Action Plan: We will work with AMHD to submit the FSRS report in a timely manner going forward. Implementation Date: July 1, 2024 Responding Official: Janet Ledoux, Administrative Officer, Child & Adolescent Mental Health Division
Level of Effort Maintenance of Effort requirement was not met. Corrective Action Plan: AMHD and CAMHD have been in discussion with SAMHSA for the last few months about meeting the maintenance of effort requirement. This issue has not been resolved. Implementation Date: July 1, 2024 Responding Offici...
Level of Effort Maintenance of Effort requirement was not met. Corrective Action Plan: AMHD and CAMHD have been in discussion with SAMHSA for the last few months about meeting the maintenance of effort requirement. This issue has not been resolved. Implementation Date: July 1, 2024 Responding Official: Courtenay Matsu, MD, Acting Administrator, Adult Mental Health Division
Reporting – FSRS Opioid STR - FSRS were not timely submitted and/or key data elements did not agree to the source documents. Corrective Action Plan: ADAD will create a procedure to implement timely reporting of the first-tier subawards of $30,000 or more Federal Funding Accountability and Transparen...
Reporting – FSRS Opioid STR - FSRS were not timely submitted and/or key data elements did not agree to the source documents. Corrective Action Plan: ADAD will create a procedure to implement timely reporting of the first-tier subawards of $30,000 or more Federal Funding Accountability and Transparency Act (FSRS) no later than the end of the month following the month in which the obligation (indicated by the start date of the new contract) is made. Upon notification of the contract and/or contract modification, the Administrative Officer will submit and update the FFATA-FSRS report until the vacant Administrative Specialist position is filled. Implementation Date: July 1, 2024 Responding Official: John Valera, Administrator and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Reporting – FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted and/or key data elements did not agree to the source documents. Corrective Action Plan: ADAD will adopt a procedure to implement timely reporting of the first-tier subawards of $30,000 or more Federal Fundin...
Reporting – FSRS Substance Abuse and Mental Health Services - FSRS were not timely submitted and/or key data elements did not agree to the source documents. Corrective Action Plan: ADAD will adopt a procedure to implement timely reporting of the first-tier subawards of $30,000 or more Federal Funding Accountability and Transparency Act (FSRS) no later than the end of the month following the month in which the obligation (indicated by the start date of the new contract) is made. Implementation Date: July 1, 2024 Responding Official: John Valera, Administrator and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division
Finding 2023-002- Student Financial Aid Cluster, Assistance Listing #84.063 and 84.268 Limestone University utilizes Jenzabar software to extract enrollment data to National Student Clearinghouse for reporting. Information was being reported to the National Clearinghouse, but in some instances, the ...
Finding 2023-002- Student Financial Aid Cluster, Assistance Listing #84.063 and 84.268 Limestone University utilizes Jenzabar software to extract enrollment data to National Student Clearinghouse for reporting. Information was being reported to the National Clearinghouse, but in some instances, the data was incorrect. Since the review of the findings, the Registrar has implemented the use of the field NSC Edit Student Data Records window, in addition to the normal enrollment process status indicated on the NSC Edit Registration Transactions window. A special status on the NSC Edit Student Data Records window will override the status on the NSC Edit Registration Transactions window. This change allows for more detailed monitoring of withdrawal dates to ensure what is being reported to NSC is accurate and timely. The Registrar reports enrollment status changes monthly to NSC to ensure enrollment changes are reported accurately and timely. The University reviewed the students in the finding, as well as reviewed all other students with the same status (withdrawn) and adjusted, if necessary, to ensure accurate student data was reported. Responsible Parties: Jeremy Whitaker, Acting President/CFO jwhitaker@limestone.edu 864-488-4539 DaOsha Pack, Controller dlpack@limestone.edu 864-488-4528 Summer Nance, Director of Financial Aid snance@limestone.edu 864-488-8251
Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the g...
Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the guidelines that were used to award students monies from this fund. During the audit, it was noted that SBCC incorrectly awarded undocumented students with monies from the Coronavirus State and Local Fiscal Recovery Funds. SBCC was not aware at the time of awarding these monies that a second guidance memo had been issued by the Community Colleges of California Chancellor’s Office (CCCCO) on Friday, January 21,2022 (Attachment B). The updated memo clearly stated that undocumented students were no longer eligible for these funds. SBCC had not updated its protocols to match the second memo due to staffing issues within th e financial aid office. Specifically, the manager of the Financial Aid Office was out on disability leave from January 26 through September 28, 2022. However, no funds were awarded during this absence. Within the new guidance, a new process stated how to corrects awards given to candidates originally eligible (undocumented students) under the first memo, but no longer eligible under the second memo. Per the second memo, any incorrectly awarded funds under the first policy were to be replaced with other funds that undocumented students are eligible to receive. Corrective Action To correct the incorrect awarding of funds to ineligible candidates, SBCC cancelled the awards to now ineligible recipients of Early Action Fund (EMASS/SRFR) and replace d them with awards from AB19 monies, which were rolled over from 22-23. SBCC also used monies from remaining HEERF/CARES funds, which allowed for awards to undocumented students. In total, SBCC corrected 16 awards totaling $48,000. SBCC’s records now reflect that no undocumented students received Coronavirus State and Local Fiscal Recovery Funds. Going forward, SBCC is now awarding under the correct guidelines. No further awards have been made to undocumented students. The fund is winding down and will be spent in full by the end of the 23-24 fiscal year.
View Audit 300097 Questioned Costs: $1
Finding 388299 (2023-001)
Significant Deficiency 2023
Reporting (Significant Deficiency) and Federal Agency: U.S. Department of Treasury Program Title: Coronavirus State and Local Fiscal Recovery Funds (“CSLFRF”) Assistance Listing Number: 21.027 Federal Award Source: Pass-Through Funding Pass-Through Entity: State of Arizona Pass-Through Identifying...
Reporting (Significant Deficiency) and Federal Agency: U.S. Department of Treasury Program Title: Coronavirus State and Local Fiscal Recovery Funds (“CSLFRF”) Assistance Listing Number: 21.027 Federal Award Source: Pass-Through Funding Pass-Through Entity: State of Arizona Pass-Through Identifying Number: GR-ARPA-JP-030122-01 Criteria – The pass-through entity’s grant agreement with the Organization requires that the Organization submit quarterly summary reports with the numbers of program participants no later than 15th of the month following each Fiscal Quarter. Condition – During our audit of the reporting requirements for the CSLFRF program, we requested quarterly summary reports and noted that they were not created nor submitted. Cause – The finding appears to be the result of staffing turnover at the Organization. The former Grants Manager resigned in May 2023 with position being absorbed by Director of Finance in July 2023. Effect and Context – Four quarterly summary reports were not submitted. Questioned Costs – None identified. Recommendation – We recommend the Organization implement policies and procedures to ensure timely and accurate reporting of required program reports. View of Responsible Officials: We are in agreement with the finding and are in the process of updating our procedures to mitigate the issues noted in the future. See our Corrective Action Plan for the fiscal year ended June 30, 2023 for additional detail. Corrective Action Plan: The Director of Finance will create a grant reporting checklist so that in the event of staff turnover, no reporting requirements are overlooked in the transition. The checklist will be created by the next quarterly grants meeting scheduled for April 4th. Subsequently, the Director of Finance will update the checklist every time a new grant is received and include a status review of all grant reporting requirements in the weekly Finance meeting and quarterly Grant meeting agendas, both of which are attended by the CEO, Director of Operations, Director of Development, and Director of Finance.
The City program leads responsible for specific grants will read the compliance requirements related to those grants prior to commencement. They will then work with Finance and Accounting to determine what the compliance requirements are along with the related deadlines. Additionally, they will also...
The City program leads responsible for specific grants will read the compliance requirements related to those grants prior to commencement. They will then work with Finance and Accounting to determine what the compliance requirements are along with the related deadlines. Additionally, they will also determine who is responsible for each compliance requirement and monitor the grant from commencement to completion to ensure each of those requirements are being complied with by the responsible parties and by the related deadlines.
This error was due to clerical oversight. The program has reviewed the processes in place with the appropriate staff and has implemented additional layers of review to ensure compliance.
This error was due to clerical oversight. The program has reviewed the processes in place with the appropriate staff and has implemented additional layers of review to ensure compliance.
2023-004: 20.205 – WB&A Trail (highway Planning and Construction) • Recommendation: We recommend that the County formalize its agreement with the pass-through entity to clarify the responsibilities for the special test’s requirements. • Explanation of disagreement with audit finding: There is no dis...
2023-004: 20.205 – WB&A Trail (highway Planning and Construction) • Recommendation: We recommend that the County formalize its agreement with the pass-through entity to clarify the responsibilities for the special test’s requirements. • Explanation of disagreement with audit finding: There is no disagreement and management agrees with the finding. • Corrective action taken in response to finding: The County Purchasing Division will follow Federal regulation to ensure all requirements are addressed either in the solicitation documents or in the project manual. • Name of the contact person responsible for corrective action: Catrice Parsons, Purchasing Agent – Central Services, Purchasing Division. • Planned completion date for the corrective action plan: June 30, 2024.
2023-003: 21.027 – COVID-19 – American rescue Plan Act Funds (US Treasury ARPA) • Recommendation: We recommend that the County prepare and maintain a written plan to ensure subrecipients are aware of the Uniform Guidance requirements. • Explanation of disagreement with audit finding: There is no dis...
2023-003: 21.027 – COVID-19 – American rescue Plan Act Funds (US Treasury ARPA) • Recommendation: We recommend that the County prepare and maintain a written plan to ensure subrecipients are aware of the Uniform Guidance requirements. • Explanation of disagreement with audit finding: There is no disagreement and management agrees with the finding. • Corrective action taken in response to finding: The County Office of Finance will create a written plan to ensure that subrecipients are aware of all the needed Uniform Guidance requirements. • Name of the contact person responsible for corrective action: Kevin McMahon, Office of Finance. • Planned completion date for the corrective action plan: June 30, 2024.
2023-002: 14.218 – CDBG – Entitlement Grants Cluster • Recommendation: We recommend the County establish and implement controls to maintain compliance with reporting requirements. • Explanation of disagreement with audit finding: There is no disagreement and management agrees with the finding. • Cor...
2023-002: 14.218 – CDBG – Entitlement Grants Cluster • Recommendation: We recommend the County establish and implement controls to maintain compliance with reporting requirements. • Explanation of disagreement with audit finding: There is no disagreement and management agrees with the finding. • Corrective action taken in response to finding: Management agrees to review the current procedures for submitting the required information through the Federal Funding Accountability and Transparency Act Subaward Reporting System to ensure the requirement for submission is met. • Name of the contact person responsible for corrective action: Kevin McMahon, Office of Finance
2023-001: 172.258, 17.259, 17.278 – WIOA Cluster • Recommendation 1: We recommend that the County prepare and maintain a written plan to ensure subrecipients are aware of the Uniform Guidance requirements. • Recommendation 2: We recommend the County performs the monitoring of the subrecipients and e...
2023-001: 172.258, 17.259, 17.278 – WIOA Cluster • Recommendation 1: We recommend that the County prepare and maintain a written plan to ensure subrecipients are aware of the Uniform Guidance requirements. • Recommendation 2: We recommend the County performs the monitoring of the subrecipients and ensure the documentation is saved within the County. • Explanation of disagreement with audit finding: There is no disagreement and management agrees with the finding. • Corrective action taken in response to finding: The County Office of Finance will (1) develop a written plan to ensure that subrecipients are aware of all the Uniform Guidance requirements; (2) due to the pandemic and the recent retirement and resignation of the top two Grant department staff members, the monitoring was not conducted during the audit period. Management will make sure that the required monitoring will be conducted and ensure compliance and proper documentation is maintained onsite. • Name of the contact person responsible for corrective action: Kevin McMahon, Office of Finance and Charles Knapp, Anne Arundel Workforce Development Corporation. • Planned completion date for the corrective action plan: June 30, 2024.
View Audit 300045 Questioned Costs: $1
We agree that in previous years, there were deficiencies in compliance with reporting requirements related to the receipt and disbursement of federal funds. There has been turnover in Business Office staff, but now that staffing has stabilized, the following procedures will be implemented regarding ...
We agree that in previous years, there were deficiencies in compliance with reporting requirements related to the receipt and disbursement of federal funds. There has been turnover in Business Office staff, but now that staffing has stabilized, the following procedures will be implemented regarding the management of federal funds:  The Senior Accountant will be responsible for the receipt and disbursement of federal funds, and for monitoring reporting requirements  The Associate Vice President for Finance and Controller will oversee the process and ensure that spending guidelines are followed and that all deadlines for reporting are met
Finding 388216 (2023-001)
Significant Deficiency 2023
Finding No. 2023-001 Gramm-Leach-Bliley Act–Student Information Security Condition During audit procedures, the auditor has noted the University risk assessment did not fully addressed all the elements required by (16 CFR 314.4). Accordingly, the following elements were missing: 1. Evidence of annua...
Finding No. 2023-001 Gramm-Leach-Bliley Act–Student Information Security Condition During audit procedures, the auditor has noted the University risk assessment did not fully addressed all the elements required by (16 CFR 314.4). Accordingly, the following elements were missing: 1. Evidence of annual security report to those charges with governance The Qualified Individual (MIS Director) which is responsible for overseeing, implementing and enforcing the Information Security Program, will submit a written report. This report will include any recommended changes, material matters, security events or violations and management responses. This report is submitted to President of the institution including the Board of Trustees at least annually on a fiscal year basis commencing with the first report due by June 30, 2024. 2. Vulnerability test Vulnerability assessments of the institution information system will include systemic scans or reviews designed to identify publicly known security vulnerabilities, at least every six months; and/or whenever there are material changes or circumstances that may have a material impact on the information security program. In addition, the institution is evaluating the possibility a network scout services (a subscription base service), which runs a daily host discovery scan across the network to detect any unauthorized devices or changes. 3. Disaster recovery plan The institution will expand the disaster recovery plan to include the following:  The main datacenters have heat and humidity detection systems as well as a fire suppression system, alarms with motion detectors, security cameras set to 24 hours recording.  The University take reasonable steps to select and retain Service Providers who will maintain safeguards to protect Covered Data in compliance with GLBA.  Disaster Recovery Teams organized to respond to disasters of various type, size, and location. These teams will mobilized depending on the parameters of the disaster. It is the responsibility of the MIS Director to determine which Disaster Recover Teams to mobilize, following the declaration of a disaster. Each team will utilize their respective procedures, technical expertise, and recovery tools to return the information systems to operational status. The datacenter and network/telecommunications infrastructure will be a highest priority. 4. No backup test was performed to assure data accuracy during year ended June 30, 2023. The Datacenter department runs a daily basis backup on a secure server, but in order to assure the store data is accurate the institution is analyzing to implement a third party Backup Verification Application. The backup application offers a verification process, which includes:  Verifying the files' integrity/they have no corruption  Monitor for ransomware traces  Making sure the file system is stable  Checks to make sure a restore will work properly, if needed Anticipated completion date: June 30, 2024.
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