Corrective Action Plans

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.

SUBRECIPIENT MONITORING West Virginia Community Advancement and Development (WV CAD) Assistance Listing Number 93.568, COVID-19 93.568 Between the years 2022 and 2023, the Weatherization Assistance Program (WAP) experienced a significant turnover in its staff. As a result of this turnover, the proper adherence to the requirement of 2 CFR 200.332(f) for verifying subrecipients was not followed during the auditing process. To ensure that this requirement is met in the future, WV CAD has taken measures to document the policies and procedures related to the financial audit requirements of 2 CFR 200.332(f) in the current WAP State Plan. A designated team member has been assigned the responsibility of maintaining a comprehensive tracking list, which includes the due dates of audits, their review dates, any necessary subrecipient corrective action plans, the dates of letter correspondence, and the uploading of all relevant documents into the divisions Shared Drive. Additionally, this team member is also responsible for downloading the audits from the Federal Audit Clearinghouse and submitting the information to the Fiscal Monitor for a thorough accounting review. These measures aim to ensure proper compliance and accountability within the Weatherization Assistance Program. This action will be implemented in February 2024.

ELIGIBILITY West Virginia Department of Health and Human Resources (DHHR) Assistance Listing Number 93.568, COVID-19 93.568 The LIHEAP policy staff within the DHHR, Bureau for Family Assistance (BFA), have worked with the Recipient Automated Payment and Information Data System (RAPIDS) team to confirm that the benefit table has been accurately entered into the RAPIDS system for fiscal year 2024. The LIHEAP policy staff will continue to review the work of the RAPIDS team to ensure that the benefit table has been accurately entered prior to the opening of LIHEAP application intake annually.

TRANSPARENCY ACT REPORTING Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558, 93.568, COVID-19 93.568 The DHHR enhanced its controls over Transparency Act reporting for LIHEAP during State Fiscal Year 2023 and met with various staff members internal and external to the DHHR (e.g., at other State agencies) to ensure everyone was aware and understood their roles in ensuring compliance on behalf of the State. Although those controls are in full effect for fiscal year 2024, the DHHR will revisit and enhance the controls to the maximum extent possible. Furthermore, the DHHR will reopen its previous submissions to the FSRS and revise the data elements to those assigned by the other State agency to their subrecipients; considering the need to consult with the DHHR spending unit and the other State agency, the anticipated date for completion is April 1, 2024.

SPECIAL TESTS AND PROVISIONS – PENALTY FOR FAILURE TO COMPLY WITH WORK VERFICATION PLAN Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558 For each data element quarter of the calendar year, the new component entry deadline and the participation hours entry deadline are established by the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA). For the first data element quarter (January, February, March), the new component entry deadline is April 30, and the participation hours entry deadline is May 5. For the second data element quarter (April, May, June), the new component entry deadline is July 31, and the participation hours entry deadline is August 5. For the third data element quarter (July, August, September), the new component entry deadline is October 31, and the participation hours entry deadline is November 5. For the fourth data element quarter (October, November, December), the new component entry deadline is January 31, and the participation hours entry deadline is February 5. To resolve the condition that led to this finding, the BFA will work with the Recipient Automated Payment and Information Data System (RAPIDS) Data Team. The BFA will request joint meetings with the RAPIDS Data Team to review sample cases and the components and hours related thereto to ensure they have been entered into the data system correctly. The meetings will take place quarterly, within five days after the participation hours entry deadlines, and will be documented accordingly.

SUBRECIPIENT MONITORING Department of Education (DOE) Assistance Listing Number 93.558, COVID-19 93.558 Program management will implement policies and procedures to ensure that the subrecipient monitoring is updated to “ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the passthrough entity must provide the best information available to describe the federal award and subaward.” The timeline for the development and initiation of the process is tentatively set for February 1, 2024.

SPECIAL TESTS AND PROVISIONS – INCOME ELIGIBILITY AND VERIFICATION SYSTEM Department of Health & Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The Division of Family Support within the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), will send the current desk guides to all WV WORKS (TANF) staff, which includes the Data Exchange desk guide and the Viewing Data Exchanges by Exchange Type desk guide. The BFA Division of Family Support will also work with the BFA Division of Professional Development to create a blackboard course for supervisors and community service managers [who supervise WV WORKS (TANF) staff] to assist the supervisors and management in identifying deficiencies regarding the IEVS system.

SPECIAL TESTS AND PROVISIONS – PENALTY FOR REFUSAL TO WORK Department of Health and Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 The TANF policy staff within the West Virginia Department of Health and Human Resources, Bureau for Family Assistance, will work with Optum, the State’s eligibility system vendor, and the Recipient Automated Payment and Information Data System (RAPIDS) team to ensure that the criteria for the population for penalty for refusal to work are interpreted and applied correctly. Policy staff will also conduct monthly reviews of a random sample of cases to which the penalty for refusal to work is applicable in order to ensure that it is being applied appropriately.

INTERNAL CONTROLS OVER SPECIAL TESTS AND PROVISIONS – CHILD SUPPORT NON-COOPERATION, PENALTY FOR REFUSAL TO WORK, AND ADULT CUSTODIAL PARENT OF CHILD UNDER SIX WHEN CHILD CARE NOT AVAILABLE Department of Health & Human Resources (DHHR) Assistance Listing Number 93.558, COVID-19 93.558 In August of 2023, the West Virginia Department of Health and Human Resources, Bureau for Family Assistance (BFA), Division of Professional Development, released a mandatory Blackboard course on Sanctions (Course ID: BFA-ITT-WV-400-2023). All staff completed the training by September 21, 2023. The BFA will repeat this mandatory training on an annual basis for all staff that have the capability to impose, approve, or remove a sanction. Reminders and desk guides will also continue to be distributed to field staff. The BFA Policy Unit will also continue its monthly reviews of RAPIDS Management reports regarding 3rd level sanctions that are being sent to the unit for review and approval.

EQUIPMENT AND REAL PROPERTY MANAGEMENT Department of Health and Human Resources (DHHR) Assistance Listing Number 93.323, COVID-19 93.323 Due to the number of administrative and programmatic offices within the DHHR and the fact that those offices are located throughout the State, the DHHR does not conduct a mass physical inventory whereby one office or person at the central level views all of the reportable assets under the DHHR’s jurisdiction. Instead, the DHHR Office of Operational Administration compiles inventory reports for each office using the fixed asset module within wvOASIS, which is the statewide accounting system. The inventory reports indicate all tagged and entered assets under each office’s location code within the DHHR. Once the reports are compiled, the Office of Operational Administration sends a report to each applicable office within the DHHR and asks the offices to locate and verify the assets in the report. The lack of documentation indicated by the auditors is due to the fact that some DHHR offices throughout the state do not return the verification to the Office of Operational Management. For the next physical inventory of fixed assets within the DHHR, which will be for the year ended June 30, 2024, the Office of Operational Administration will monitor and regulate each office more stringently and will increase its efforts to ensure that each office completes the verification and returns it to the Office of Operational Administration in a timely manner. For offices that do not respond within a timeframe deemed reasonable by the Office of Operational Administration, they will inform and request assistance from a higher level of authority within the DHHR, such as the Executive Director of Operations.

SUBRECIPIENT CASH MANAGEMENT Department of Health and Human Resources (DHHR) Assistance Listing Number 93.323, COVID-19 93.323 The West Virginia Department of Health and Human Resources, Bureau for Public Health (BPH), will analyze the condition that led to this finding in an effort to determine if the subrecipient has any excess cash on hand to date. In an effort to enhance internal controls, the BPH has initiated mandatory retraining for all staff members who are responsible for reviewing subrecipient expenditure reports and processing invoices. The retraining effort has already begun and will be conducted on a monthly basis for existing employees and at the start of employment for new staff members. The BPH has also developed and implemented a Subrecipient Grant Expenditure Checklist and Subrecipient Grant Invoice Checklist. The checklists outline the steps to take when reviewing subrecipient expenditures and invoices; provide a means to verify whether the grantee is under the 10% threshold established by the BPH when monitoring cash management for subrecipients of the Epidemiology program, including a means to compare expenditures between reporting periods; and require the staff member to certify that the reviews were completed.

INTERNAL CONTROLS OVER SUBRECIPIENT MONITORING Department of Health and Human Resources (DHHR) Assistance Listing Number 93.788, 93.323, COVID-19 93.323, 93.575, 93.596, COVID-19 93.575, 93.558, COVID-19 93.558 This finding is a repeat of prior year finding 2022-041. As related to the first paragraph of the corrective action plan for 2022-041, the new risk assessment form and related processes are still under review within the DHHR. Regarding the second paragraph of that corrective action plan, the DHHR developed a series of certifications that will replace the mandatory monitoring checklist currently in use within the DHHR. The certifications will be part of the workflow within the DHHR's subrecipient Grants Management Solution system (CRM). One of the certifications will be based on the requirements for pass-through entities within the Code of Federal Regulations at 2 CFR 200.332(b) and will require DHHR spending units to evaluate each subrecipient's risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate level of monitoring to apply to the award. The level of monitoring applied to a particular subrecipient for an individual grant award will depend on multiple factors, such as the subrecipient's prior experience with the same or similar grant awards or programs; the subrecipient's prior experience with any type of grant award or program; the results of previous external audits or internal reviews, including whether or not the subrecipient receives a Single Audit in accordance with 2 CFR 200 Subpart F ("Audit Requirements"); and whether the subrecipient has new personnel or new or substantially changed systems. When a DHHR spending unit considers these [and other] factors prior to awarding a grant, they are in essence evaluating the subrecipient's risk of noncompliance with federal statutes, regulations, and the terms and conditions of the grant award. If an evaluation of such factors proves that the subrecipient's risk of noncompliance is high, the award will still be made to address a programmatic need, and special conditions that correspond to the degree of risk may be applied to the award. In other words, the DHHR spending unit may adjust or impose specific and additional award conditions upon a subrecipient if the evaluation proves that such additional conditions are appropriate. Special conditions would include but not be limited to requiring payments as reimbursements rather than advance payments; withholding authority to process to the next phase until receipt of evidence of acceptable performance within a given performance period; requiring additional, more detailed financial reports; requiring additional project monitoring; requiring the subrecipient to obtain technical or management assistance; and establishing additional prior approvals. Although none of these requirements are new within the DHHR, adding a certification directly within the CRM workflow to address such matters will provide the DHHR with an ability to embed various controls directly within the system, provide a higher level of assurance over the risk assessment and monitoring process, increase accountability on the part of the spending units, and provide a more effective audit trail. Given these expanded goals and the need to work with a contractor on adding these additional controls within the CRM system, the DHHR plans to implement the controls via a manual process first, with a desired date for completion of May 31, 2024.

MAINTENANCE OF EFFORT Department of Education (DOE) Assistance Listing Number 84.425, COVID-19 84.425 The Maintenance of Effort (MOE) calculation is in process. A waiver was requested and approved for the FY 2023 MOE data. The MOE will be completed by March 15, 2024.

INTERNAL CONTROLS OVER ALLOWABLE COSTS AND COST PRINCIPLES West Virginia State University (WVSU) Assistance Listing Number COVID-19 84.425J In accordance with the wvOASIS/Kronos procedural guidance, WVSU will immediately implement measures within the payroll administration office to send reminders, to employees and supervisor/manager, in the sequence of three days prior to deadline and two days prior to deadline to approve all timecards. In the event an employee timecard has not received approval, employee and supervisor/manager understand that pay will be withheld for that pay period until approval is received. Further, WVSU will develop, document, and communicate a written procedure for Time and Leave by March 31, 2024 that includes proper internal controls for timesheet approval. This procedure will be communicated and reinforced through campus wide emails and via Supervisor/Manager trainings hosted by University Human Resources Office.

ALLOWABILITY West Liberty University (WLU) Assistance Listing Number COVID-19 84.425F, 84.425M WLU’s CFO and Controller will have the Student Accounts Manager print and save documentation from the Banner System as evidence of supporting future calculations. WLU’s CFO and Controller will also review all invoices for proper approvals before payments are made and changed to HEERF or any other future programs that arise will be dealt with accordingly.

CASH MANAGEMENT Bluefield State University and West Virginia State University Assistance Listing Number 84.425J Bluefield State University (BSU) response Effective June 2024, BSU will draw down funds on appropriate expenditures that have already been disbursed to avoid any cash management violations. West Virginia State University (WVSU) response Currently all funds have been disbursed for HEERF awards P425E201113, P425F201736, and P425J200056. WVSU will reconcile the SEFA receipts and disbursements to internal data to locate the discrepancy and make the necessary corrections. Further, WVSU will review and update internal controls related to cash management rules to ensure compliance for drawdowns and disbursements.

ALLOWABILITY Department of Education (DOE) Assistance Listing Number COVID-19 84.425D, 84.425U The DOE plans to strengthen its internal controls by putting in place a review of procurement procedures prior to the Local Educational Agency (LEA) finalizing a purchase. This control will entail DOE working with LEAs to monitor their internal control procedures for procurement and testing these procedures randomly throughout the year. The questioned costs were first identified as stringing in the FY21 monitoring. Subsequently, there was a repeat finding with the same vendor in FY22 which raised additional questions. The LEA was required to do an additional training put on by the DOE to improve knowledge/procedures of WV Policy 8200. The DOE plans to address these issues by working with the LEA to move the expenses off federal monies. Along with working with the LEA, the DOE is working with the FBI, West Virginia State Police, and the Office of the Inspector General to investigate the spending and the vendor themselves.

REPORTING Department of Education (DOE) Assistance Listing Number COVID-19 84.425D, 84.425R 84.425U, 84.425V Effective February 2024, the DOE plans to continue to enforce the existing policies and procedures in place along with ensuring all required documentation is retained for review. The DOE plans to review the ESSER Reporting Workbook by testing several indicator values i.e. expenditure amounts, demographic data, etc. There will be an approval process put in place once the Local Education Agency (LEA) submits the reports to the state. This approval process will include reviewing the edit checks with the LEA prior to final certification of data. Certification data will include an email from the LEA approving the final copy of the ESSER Reporting Workbook.

TRANSPARENCY ACT REPORTING Department of Education (DOE) Assistance Listing Number COVID-19 84.425C, COVID-19 84.425D The West Virginia Department of Education, Office of Internal Operations have established internal controls and procedures over the FFATA reporting and were set in place as of July 1, 2023. These procedures involve a second reviewer of the monthly FFATA reports and a signature of approval prior to reporting each month.

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.

INTERNAL CONTROLS OVER CASH MANAGEMENT Bluefield State University, Fairmont State University, Mountwest Community and Technical College, and West Virginia Northern Community College Assistance Listing Number 84.007, 84.033, 84.063, 84.268 Bluefield State University (BSU) response By June 2024, BSU will ensure that if a drawdown approval occurs in person with the Director of Financial Aid, the approval signature will be obtained during the meeting. Fairmont State University (FSU) response Effective February 2023, FSU has added a second level review control and it was put into place to address the inadequate internal controls identified. Mountwest Community and Technical College (MCTC) response Effective February 2024, MCTC will make the appropriate effort to obtain "inked" approvals prior to initiating drawdown requests through G5/G6 to serve as proof of double verification. However, MCTC does note that single reviews are completed prior to any drawdown request as evident of the relationship between the requestor and initiator of the drawdown in G5/G6 to ensure accuracy and completeness. West Virginia Northern Community College (WVNCC) response Beginning April 1st, 2024, WVNCC will establish an electronic repository specifically designated for the retention of evidence that a review and approval of all drawdown requests occur. The repository will be reviewed internally on a quarterly basis by the CFO and any anomalies will immediately be brought to the attention of staff and resolved.

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.