Corrective Action Plans

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Corrective action plan: TANF/SEGIF: To ensure that correct UEIs are included on all Early Childhood Initiatives (ECI) contracts, the Early Childhood Initiatives (ECI) program has implemented a review system of the contracts and amendments prior to routing them through CAPPS FIN. The contract develop...
Corrective action plan: TANF/SEGIF: To ensure that correct UEIs are included on all Early Childhood Initiatives (ECI) contracts, the Early Childhood Initiatives (ECI) program has implemented a review system of the contracts and amendments prior to routing them through CAPPS FIN. The contract developer will create the document, and the assigned performance specialist will review the data included in the contract/amendment to ensure it is accurate before the contract is routed for approval. SUBG: Behavioral Health Services’ pass-through agreements effective September 1, 2026, will include 2 CFR §200.332 requirements. Implementation dates: TANF/SEGIF: September 1, 2025 SUBG: December 31, 2026 Responsible persons: TANF/SEGIF: Janene Roch, Manager, ECI Contracts and Finance SUBG: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security ...
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security Office for continuation of periodic reconciliation of HR data and network accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Work with Human Resources to establish a schedule of periodic reconciliation for HR data and case management application accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Review existing business process for offboarding separated employees and provided recommendations to HR for training and communication for staff. Recommendations to be provided by May 1, 2026. • Determine what technology solution may be needed by August 31, 2026, with consideration of effectiveness of mitigation actions, as noted above. Implementation dates: See Corrective action plan Responsible person: Angie Lindemann, Deputy Chief Information Officer
Corrective action plan: Program staff will ensure that a formal review by the Team Lead and the Manager of Fiscal and Reporting is completed prior to submission. The Team Lead will initiate the process by obtaining the obligation amount from the LIHEAP Contract Specialist and entering the amount int...
Corrective action plan: Program staff will ensure that a formal review by the Team Lead and the Manager of Fiscal and Reporting is completed prior to submission. The Team Lead will initiate the process by obtaining the obligation amount from the LIHEAP Contract Specialist and entering the amount into the quarterly report. The Manager of Fiscal and Reporting will review and confirm the amount to be submitted. Implementation date: April 30, 2026 Responsible persons: Michael De Young, Director of Community Affairs Cathy Jung, Senior Manager of Finance and Reporting
Corrective action plan: HHSC will conduct an end-to-end review of the sanctions process to identify and implement any needed changes to the business process, training, or system. Implementation date: May 31, 2026 Responsible person: Carrie Robertson, Manager, Strategy and Innovation–Business Integra...
Corrective action plan: HHSC will conduct an end-to-end review of the sanctions process to identify and implement any needed changes to the business process, training, or system. Implementation date: May 31, 2026 Responsible person: Carrie Robertson, Manager, Strategy and Innovation–Business Integration and Support
Corrective action plan: THECB ITS will: • Develop and implement a standardized process for all user access reviews, including a required template which documents review date, reviewer identity, scope, results, and remediation actions. • Maintain all documentation in a centralized location on our ITS...
Corrective action plan: THECB ITS will: • Develop and implement a standardized process for all user access reviews, including a required template which documents review date, reviewer identity, scope, results, and remediation actions. • Maintain all documentation in a centralized location on our ITS SharePoint site. • Implement regular monitoring to ensure reviews are performed time, and the proper documentation is retained. • We will seek to automate processes where possible. Implementation date: July 1, 2026 Responsible person: Layla Young, Brian Nolte, Joel Anguiano
Corrective action plan: TCEQ will provide targeted training to program staff on federal procurement requirements, including the necessity of coordinating all purchases through the Procurements & Contracts Section and completing required vendor compliance checks. Training will emphasize procedures fo...
Corrective action plan: TCEQ will provide targeted training to program staff on federal procurement requirements, including the necessity of coordinating all purchases through the Procurements & Contracts Section and completing required vendor compliance checks. Training will emphasize procedures for sole source or limited source procurements and reinforce staff responsibilities under 2 CFR procurement and internal control standards. Regular refresher sessions and documented guidance will help ensure consistent understanding and adherence to required procurement practices across all program areas. Implementation date: May 31, 2026 Responsible person: Yolanda Davis, Deputy Director, Financial Administration Division
Corrective action plan: ITS Management will establish a formal, documented user access review program applicable to both privileged and non-privileged network users. Key actions include: 1. Policy Updates: Revise information technology access control policies and procedures to re-quire periodic (at ...
Corrective action plan: ITS Management will establish a formal, documented user access review program applicable to both privileged and non-privileged network users. Key actions include: 1. Policy Updates: Revise information technology access control policies and procedures to re-quire periodic (at least annual) reviews of all network user access. 2. Standardized Process and Documentation: Implement a consistent, documented review process and maintain records in a centralized repository to ensure accountability and auditability. 3. Monitoring and Oversight: Implement oversight procedures to track completion of access re-views and remediation of identified issues, with reporting to IT and information security leadership to support governance. Implementation dates: 1. Policy and procedure updates: Expected completion by April 30, 2026 2. Standardized process and repository implementation: Expected completion by May 31, 2026 3. First completed annual review under the revised process: Expected completion by June 30, 2026 Responsible persons: Tara Mitchell, Director of IT Operations Sean Peterson, Chief Information Officer
Corrective action plan: A formalized process will be implemented, utilizing Standard Operating Procedures, to cover changes of hardware or software in relationship with network and infrastructure components. A change management tracking and approval system is under development that will be utilized ...
Corrective action plan: A formalized process will be implemented, utilizing Standard Operating Procedures, to cover changes of hardware or software in relationship with network and infrastructure components. A change management tracking and approval system is under development that will be utilized to track and provide audit logs of all network and infrastructure changes. Implementation date: August 31, 2026 Responsible person: Lars Hjaltman, CIO
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that ...
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that will aid in the process and will be implemented this year. • IT will document quarterly access reviews which are already done. • IT will work on enhancing automation and controls; Will utilize AI to assist. Implementation date: May 2026 Responsible person: Chris Bunton, CIO, Texas Department of Agriculture
Management Response: The University agrees with the finding. The identified issue was isolated and only impacted fall graduates. This issue was fully addressed when the university filed its fall 2025 enrollment reporting. The university has conducted an internal audit to identify students that were ...
Management Response: The University agrees with the finding. The identified issue was isolated and only impacted fall graduates. This issue was fully addressed when the university filed its fall 2025 enrollment reporting. The university has conducted an internal audit to identify students that were reported incorrectly and has manually updated files to ensure dates were properly reflected. At current state, internal monitoring and manual edits are made if discrepancies appear. The university has been in contact with PeopleSoft software related to the issue. Should the software issue not be resolved, the university plans to continue with manual edits to ensure proper reporting. Contact Person: Stacy Ramsey, University Registrar srramse@ilstu.edu Completion Date: December 2025
Information on the federal program: Subject: Special Education Cluster (IDEA) – Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal ...
Information on the federal program: Subject: Special Education Cluster (IDEA) – Period of Performance Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 22611-047-PN01, 22611-047-ARP, 22619-047-PN01, 22619-047-ARP Pass-Through Entity: Indiana Department of Education Compliance Requirement: Period of Performance Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Special Education Cluster program and Period of Performance compliance requirements. Context: During fiscal year 2023-24, the School Corporation was a member of Cooperative School Services (Cooperative). The Cooperative operated the special education programs and spent the federal money on behalf of its member schools. As the grant agreement was between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. For Special Education Cluster awards, funds must be obligated during the 27 months, extending from July 1 of the fiscal year for which the funds were appropriated through September 30 of the second following fiscal year. When testing transactions occurred in the liquidation period for the 22611-047-PN01, 22611-047-ARP, 22619-047-PN01 and 22619-047-ARP grant awards, two exceptions were identified in the sample of five transactions. For the above listed awards, costs must be obligated by September 30, 2023. For the two identified exceptions, an initial purchase order was made in September, but the ultimate transaction was paid to a separate vendor than the original purchase order, and this obligation was incurred in November 2023. This issue was isolated to fiscal year 2024. No costs incurred outside of the period of performance were identified in fiscal year 2025. Views of Responsible Officials and Corrective Action Plan: Management disagrees with part of the finding. The term “obligate” can be interpreted in various ways within our context. While we have a purchase order that was completed by September 30, we do agree that we changed vendors after September 30 and paid the non-public school directly. We agree with the finding that direct payment to a non-public school is not allowable. The purchase order is an internal written commitment to acquire the items/supplies, but it is not a binding written agreement to acquire “property” when we are purchasing supplies until it is provided to the vendor. The purchase order is authorization and approval to purchase the items/supplies. Once the purchase order is provided to the vendor, it is committed and is the binding written agreement. The invoice is an order to pay the obligation. Responsible Party and Timeline for Completion: Corrective action plan has been implemented as this finding impacted fiscal year 2024 but did not recur in fiscal year 2025. Sarah Claton, Cooperative School Services director, and Tracy Albertson, Director of Finance, will oversee the corrective action plan to monitor the cooperative on an ongoing basis.
The City will establish procedures whereby the Clerk and Manager will prepare the Schedule of Expenditures of Federal Awards (SEFA) at each fiscal year end.
The City will establish procedures whereby the Clerk and Manager will prepare the Schedule of Expenditures of Federal Awards (SEFA) at each fiscal year end.
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
Federation of Appalachian Housing Enterprises, Inc. acknowledges that we should have been filing information for all of our grantees over $30,000 on the FFATA Sub-award Reporting System website. We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the w...
Federation of Appalachian Housing Enterprises, Inc. acknowledges that we should have been filing information for all of our grantees over $30,000 on the FFATA Sub-award Reporting System website. We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the website, and we have included FFATA registration as a step in the creation of all future RDCA grantees.
Coronavirus State and Local Fiscal Recovery Funds Procurement, Suspension, and Debarment Planned Corrective Action: The City implemented a Vendor’s Doing Business Policy in FY 2025-26 requiring all new vendors be searched on SAM.gov and California Secretary of State prior to executing a contract, wi...
Coronavirus State and Local Fiscal Recovery Funds Procurement, Suspension, and Debarment Planned Corrective Action: The City implemented a Vendor’s Doing Business Policy in FY 2025-26 requiring all new vendors be searched on SAM.gov and California Secretary of State prior to executing a contract, with emphasis on federal awards. Anticipated Completion Date: March 9, 2026 Responsible Contact Person: Gretchen Hoskins, Finance Director
Finding Reference: 2025-001 – Reporting Condition: During testing of reporting compliance for major federal programs, we selected three of twelve monthly OAF reports submitted during the fiscal year. For each month tested, reported amounts did not reconcile to MOFC’s internal Poundage Distribution r...
Finding Reference: 2025-001 – Reporting Condition: During testing of reporting compliance for major federal programs, we selected three of twelve monthly OAF reports submitted during the fiscal year. For each month tested, reported amounts did not reconcile to MOFC’s internal Poundage Distribution reports and Product Code – Agencies by County reports. Specifically, we identified material variances between the OAF reports and internal distribution records, including: October 2024: ACP distributions were omitted from the OAF report, resulting in a variance of approximately 821,528 pounds (projected dollar impact of $262,889). January 2025: VA/Holiday Purchase distributions were omitted from the OAF report, resulting in a variance of approximately 310,898 pounds (projected dollar impact of $155,449). June 2025: Donated distributions, primarily Direct Retail Pickup (DRP) quantities, were omitted from the OAF report, resulting in a variance of approximately 933,505 pounds (projected dollar impact of $1,764,324). Additional differences were noted in purchased distributions of 40,399 pounds (projected dollar impact of $16,968). Although management provided explanations indicating that certain distributions were omitted in error or excluded due to differences in reporting scope, MOFC did not maintain documented reconciliations supporting the reported amounts. Evidence of review and approval demonstrating that differences were identified, investigated, and resolved prior to report submission was not provided. Views of Responsible Officials Items 1 & 2 are both failures of a report in our former ERP to include exception components and needed to be added manually when reporting. This is a result of human error. Item 3 is a result of a WIP component currently being installed into the new ERP to add in programmatic data for agency pickups. This is currently added manually for reporting purposes – also human error. Planned Corrective Action: Implementation of the Direct Retail Pickup poundage integrations into the current ERP will negate the necessity to manually enter the numbers. While this install is occurring, we will continue to manually update. Anticipated Completion Date: Initial discussions have occurred with an anticipated solution provided, tested and approved before the end of FY26 timeframe.
Finding 2025-1 Financial Statement Preparation Status: On-going Reason for Recurrence: The Authority has discussed the finding but must consider the cost of professional resources to complete a set of drafted Authority financial statements.
Finding 2025-1 Financial Statement Preparation Status: On-going Reason for Recurrence: The Authority has discussed the finding but must consider the cost of professional resources to complete a set of drafted Authority financial statements.
We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager, and Jo...
We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager, and Joei Harrison, Finance Director. Corrective Action Plan: The City will complete all required compliance reporting for CDBG activities in the futures. Anticipated Completion Date: July 2025
Finding 2025-002 Reporting Department’s Response: Management agrees with this finding. Corrective Action: This issue arose during the onboarding of students admitted through a teach-out arrangement with a closing institution. Because these students entered under program structures that differed from...
Finding 2025-002 Reporting Department’s Response: Management agrees with this finding. Corrective Action: This issue arose during the onboarding of students admitted through a teach-out arrangement with a closing institution. Because these students entered under program structures that differed from NUNM’s standard enrollment models, some of the information initially received did not align with NUNM’s financial aid packaging assumptions. In two cases, cost of attendance calculations reflected full-time status when the program design required three-quarter-time treatment. While the situation was limited to a small number of students within a unique population, management recognizes that our internal coordination processes did not sufficiently account for the complexity of the teach-out transition. In particular, clearer confirmation of enrollment status and program structure should have occurred before aid was packaged and originated. Management is strengthening procedures for any future teach-out, transfer, or non-standard admissions cohorts to ensure accurate and compliant packaging from the outset. Going forward, NUNM will implement the following controls: • A standardized handoff process from Admissions to Financial Aid for special populations that documents program structure, term length, and expected enrollment level prior to packaging. • A secondary review requirement for initial aid awards for new program types or cohorts before loans are originated. • Regular cross-functional checkpoints between Admissions and Financial Aid during the setup of non-standard programs. Management views this experience as an opportunity to improve coordination and compliance during periods of institutional transition and is committed to maintaining strong controls over Title IV packaging and cost of attendance calculations. Contact: Jerry Bores Anticipated Completion Date: Immediately
We will be updating our internal procurement policy. We will also review our policy and train staff on it annually as well as with new hires during orientation to ensure that the policy is understood and followed.
We will be updating our internal procurement policy. We will also review our policy and train staff on it annually as well as with new hires during orientation to ensure that the policy is understood and followed.
Subrecipient Monitoring Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV OSP has implemented a comprehensive policies and procedures document covering ...
Subrecipient Monitoring Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV OSP has implemented a comprehensive policies and procedures document covering the entire subrecipient lifecycle, which includes internal controls such as a checklist, review of risk before issuance, a biannual sub monitoring review of financial audit, and authorized purposes review. ● How compliance and performance will be measured and documented for future audit, management and performance review. The internal controls will be added by OSP to enhance sub monitoring to include a review of the budget-to-actuals for subrecipients' invoices for alignment to the project. Additional guidelines will be included in the invoice review process for the principal investigators as well. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management staff, independent of the preparer, will review and sign off on each report. This revi...
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management staff, independent of the preparer, will review and sign off on each report. This review process will include verifying that all information is correctly entered. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured through the independent review process, where management will verify and sign off on each report to ensure accuracy. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Subrecipient Monitoring Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV OSP has implemented a comprehensive policies and procedures document covering ...
Subrecipient Monitoring Responses UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV OSP has implemented a comprehensive policies and procedures document covering the entire subrecipient lifecycle, which includes internal controls such as a checklist, review of risk before issuance, a biannual sub monitoring review of financial audit, and authorized purposes review. ● How compliance and performance will be measured and documented for future audit, management and performance review. Per the UNLV OSP policy, documentation is required throughout the lifecycle and will be used for future audits. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management staff, independent of preparer, will review and sign off on each report. This review p...
Reporting Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Management staff, independent of preparer, will review and sign off on each report. This review process will include verifying that all information is correctly entered. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured through the independent review process, where management will verify and sign off on each report to ensure accuracy. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Associate Director of Post Award Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN Office of Grants and Contracts Post-Award Management has advised the grant’s principal invest...
Reporting Responses CSN – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; CSN Office of Grants and Contracts Post-Award Management has advised the grant’s principal investigator (PI) that underlying documentations must match the data reported on the Annual Performance Reports submitted to the award sponsor. The CSN GEAR UP PI and GEAR UP First Year College Advisor have refined the reporting and record keeping process to ensure accurate reporting and supporting documentation is kept in compliance with the grant. The Senior Accountant of Grants and Contracts also reviews the data before each report is submitted to the sponsor. ● How compliance and performance will be measured and documented for future audit, management and performance review. CSN GEAR UP PI and GEAR UP First Year College Advisor will continue to ensure accurate reporting and supporting documentation is kept in compliance. CSN Office of Grants and Contracts Post-Award Management will continue to communicate with PIs to ensure all reports have been reviewed for adequate and accurate supporting documentation prior to submission to the sponsor. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. CSN Program Director, who is the Gaining Early Awareness and Readiness for Undergraduate Programs (GEAR UP) Principal Investigator (PI), is accountable for exercising oversight and responsibility. GBC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; o Establishment of a formal review and approval workflow requiring secondary review by the Grants Office of participants numbers prior to submission of any financial or performance report. This will require: (1) Identification of the reporting period; (2) Review of all source documents supporting reported totals; and, (3) Mathematical reconciliation of reported figures o Training provided to grant program staff and administrative personnel on documentation standards and reporting accuracy expectations. o All corrective actions were implemented immediately upon identification of the finding and will be fully in place within 30 days of notification. The revised procedures are now standard practice for all grants reporting participant numbers. ● How compliance and performance will be measured and documented for future audit, management and performance review. o Reports may not be submitted to the pass-through entity without documented secondary review and written approval from the Grants Director or the Grant and Asset Coordinator. o Interim and final program reports will be reviewed to ensure: (1) Participant totals match underlying documentation; (2) Source documentation is retained and accessible; and, (3) Approval signatures are present prior to submission. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. o The Grants Director and the Director of Business Operations are responsible for oversight of grant compliance. NSU – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; NSU has reviewed the finding and has put additional measures in place to ensure compliance. Staff responsible for preparing reports were retrained and multi-layered quality checks have been implemented to safeguard integrity of data entered in shared databases. NSU’s multi-layered quality checks include written confirmations from staff involved in service activities and backup of documentation within NSU’s local storage to support the numbers being reported. The latter represents a move away from using a database that is accessible to multiple institutions to a centrally controlled location within NSU. This process outlined herein was implemented in August 2025 and ensures that the source documentation reconciles with reports and is available for auditing purposes. ● How compliance and performance will be measured and documented for future audit, management and performance review. To ensure compliance, NSU staff who are responsible for the program and technical reporting have reviewed and updated internal policies and procedures relating to reporting. Performance targets and benchmarks have been reestablished and will be measured at set intervals. Any errors detected will be documented and remedied. Additionally, errors will serve as the basis for continuous improvement processes and retraining as needed. These will be documented in performance reviews. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The NSU GEAR UP Principal Investigator and First-Year College Advisor Supervisor are responsible and accountable for ensuring reporting is supported by underlying records. TMCC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; TMCC reports on the number of participants for all services rendered under the GEAR UP grant through both the Interim Progress Report (IPR) and the Final Progress Report (FPR). The identified issue concerns a discrepancy between the reported participant count on the IPR and the underlying supporting records. To ensure data accuracy going forward, TMCC will implement an additional review of participant reporting. Prior to the submission of progress reports, a second technical reviewer within the GEAR UP team would verify the participant counts entered into GEARS (GEAR UP’s designated data-reporting platform) against the supporting documentation (the attendance sheet). Should a discrepancy be identified, the GEAR UP team will follow up with the individual responsible for the data entry on GEARS to reconcile the difference. This may include requesting correction of data entry errors or obtaining additional documentation to support the reported participant count, as appropriate. Additionally, attendance sign-in sheets will be collected and retained by TMCC staff to allow for direct verification prior to reporting. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance and performance will be measured by the implementation of a second reviewer for the participant data reported through GEARS and included in the progress reporting. This review can be documented through an internal checklist, internal communication, or other appropriate records demonstrating that the participant data was reviewed and validated prior to the submission of progress reports. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Primary responsibility for accurate participant reporting will remain with the TMCC First Year College Advisor (FYCA) or other designated staff responsible for preparing grant performance reports. Responsibility for completing the secondary verification review will be assigned to a designated GEAR UP technical reviewer or program staff member who is independent of the initial data entry and report preparation. If repeat or similar observations occur, program leadership will evaluate adherence to established procedures and implement additional corrective actions, which may include staff retraining, revision of internal procedures, or reassignment of reporting responsibilities, as appropriate. UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The UNLV OSP will continue to work with PIs to ensure there is a documented review of progress reports. PIs will be expected to demonstrate review of progress reports and provide supporting documentation for data. Additionally, if reports require financial expenditures, the Office of Sponsored Programs will require validation before submission. Communication dissemination will occur twice within the academic year. ● How compliance and performance will be measured and documented for future audit, management and performance review. UNLV OSP will continue communications through Research Weekly (an internal communication newsletter) to remind PIs to ensure timely submission of progress reports and retention of records such as, lab notes, testing, populations served, activities performed, etc. to demonstrate activities supported by the grant. UNLV OSP will maintain communications with PIs to perform monitoring throughout the life of the award. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility along with the applicable Deans. UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; All participant counts reported in Interim Progress Reports will be supported by retained underlying source documentation that directly reconcile to the reported totals. Standard documentation expectations and retention requirements will be communicated to program staff. ● How compliance and performance will be measured and documented for future audit, management and performance review. Compliance will be measured through pre-submission review of reported participant data against underlying records and through post-submission spot checks conducted by Program Director. Documentation supporting reported counts will be retained in the official project file and made available for future audit, management review, and internal monitoring. Evidence of reconciliation will be documented via checklists or certifications retained with the report. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Program Director WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Sponsors have determined grant practices and required reporting documentation, which have not been consistently required or expected of subrecipients. WNC will maintain its own sign-in sheets and documentation for all grant-sponsored activities to ensure compliance with overall grant requirements. The corrective action was implemented in July 2025. ● How compliance and performance will be measured and documented for future audit, management and performance review. The GEAR Up coordinator will create and maintain sign-in sheets or other documentation for every grant-sponsored activity. The coordinator will maintain records in accordance with federal and state guidance and will ensure that supporting documentation is sufficient to support the reported figures. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. Final responsibility and accountability fall on the GEAR Up coordinator and grant administrator. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
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