Corrective Action Plans

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Recommendation: The Organization should formally adopt a written procurement policy that is in compliance with the Uniform Guidance.
Recommendation: The Organization should formally adopt a written procurement policy that is in compliance with the Uniform Guidance.
Views of Responsible Officials and planned Corrective Actions: The Organization concurs with the recommendation to adopt a written procurement policy to be in compliance with Uniform Guidance Requirements.
Views of Responsible Officials and planned Corrective Actions: The Organization concurs with the recommendation to adopt a written procurement policy to be in compliance with Uniform Guidance Requirements.
Recommendation: Although the small size of the Organization’s accounting staff limits the extent of segregation of duties, we believe certain steps could be taken to separate incompatible duties.
Recommendation: Although the small size of the Organization’s accounting staff limits the extent of segregation of duties, we believe certain steps could be taken to separate incompatible duties.
Views of responsible officials and planned corrective actions: The Board concurs with the recommendations that the Organization would be best served by segregating fiscal duties as outlined above. At the current time, the additional staff sufficient to implement the recommendation is not practical t...
Views of responsible officials and planned corrective actions: The Board concurs with the recommendations that the Organization would be best served by segregating fiscal duties as outlined above. At the current time, the additional staff sufficient to implement the recommendation is not practical to move toward a level of activity which may allow us to fully implement the recommendation. The Organization’s Board of Directors will remain involved in the financial affairs of the Organization to provide oversight and independent review functions.
Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting ...
Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting the financial statements, related footnote disclosures and SEFA in accordance with the accounting principles generally accepted in the United States of America (U.S. GAAP).
Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than...
Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than the competence required to prepare the financial statements, related footnote disclosures and SEFA in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP).
Finding 2025-001 Condition: Semi-annual time and effort certifications were not maintained for grant employees whose salaries and wages were not supported by detailed time records. Corrective Action Planned: Controls will be implemented to ensure all time and effort certifications are completed and ...
Finding 2025-001 Condition: Semi-annual time and effort certifications were not maintained for grant employees whose salaries and wages were not supported by detailed time records. Corrective Action Planned: Controls will be implemented to ensure all time and effort certifications are completed and maintained by the appropriate grant administrators for all grant employees. Anticipated Completion Date: June 30, 2026 Contact: Larry Azer, School Business Manager
We will continue to monitor our procedures and implement additional controls where possible.
We will continue to monitor our procedures and implement additional controls where possible.
Auditors Recommendation: We recommend that management implement and enforce procedures to ensure Replacement Reserve deposits are made in the required amounts and at the required frequency, including periodic review by management to ensure ongoing compliance with HUD requirements. Action Taken: Goin...
Auditors Recommendation: We recommend that management implement and enforce procedures to ensure Replacement Reserve deposits are made in the required amounts and at the required frequency, including periodic review by management to ensure ongoing compliance with HUD requirements. Action Taken: Going forward, we will create a procedure for the Finance team to make the required deposits to the HUD reserve accounts In the future, noting, dates, and amounts to make. They will be added to our month end reconciliations. We have caught up, and made necessary deposits to date, and are current.
Auditors Recommendation: We recommend that management implement and enforce procedures requiring documented HUD approval prior to any use of replacement reserve funds, including review and approval by appropriate management personnel, to ensure compliance with HUD requirements. Action Taken: We were...
Auditors Recommendation: We recommend that management implement and enforce procedures requiring documented HUD approval prior to any use of replacement reserve funds, including review and approval by appropriate management personnel, to ensure compliance with HUD requirements. Action Taken: We were not aware that use of these funds required HUD approval. We are creating a policy to prevent any use of the HUD Reserve Account funds, without prior approval from HUD. We have subsequently returned all funds that were borrowed with prior HUD authorization, and will not access them in the future, without proper approval from HUD.
Corrective Action Planned: The auditee acknowledges that it did not have adequate procedures in place to identify all federal funding sources, track cumulative federal expenditures, and determine the applicability of Single Audit requirements.• Federal Funding Identification Procedures: Establish fo...
Corrective Action Planned: The auditee acknowledges that it did not have adequate procedures in place to identify all federal funding sources, track cumulative federal expenditures, and determine the applicability of Single Audit requirements.• Federal Funding Identification Procedures: Establish formal procedures to review all grant agreements, contracts, and funding documents to identify federal funding sources, including Assistance Listing (ALN) numbers and pass-through entity information. • Centralized Tracking of Federal Expenditures: Implement a tracking mechanism ( e.g., spreadsheet or accounting system enhancement) to record and monitor all federal expenditures by program throughout the fiscal year. • Periodic Monitoring of Single Audit Threshold: Perform quarterly reviews of cumulative federal expenditures to determine whether the dollar threshold (currently $1 million) for a Single Audit has been met. • SEFA Preparation and Review Controls: Develop a standardized process for preparing the Schedule of Expenditures of Federal Awards (SEFA), including a supervisory review to ensure completeness and accuracy prior to issuance. • Training and Awareness: Provide training to key personnel involved in financial reporting and grant management on Uniform Guidance requirements, including SEFA preparation and Single Audit thresholds. Anticipated Completion Date: September 30, 2026 Planned Monitoring and Follow-Up: Management will periodically review compliance with the new procedures and controls to ensure that all federal funding is properly identified, tracked, and reported, and that Single Audit requirements are evaluated timely.
Management acknowledges the audit finding related to the absence of a formally documented written information security program. While VEEB has implemented certain administrative and technical safeguards to protect sensitive information, these practices have not been consolidated into a single, writt...
Management acknowledges the audit finding related to the absence of a formally documented written information security program. While VEEB has implemented certain administrative and technical safeguards to protect sensitive information, these practices have not been consolidated into a single, written information security program as required. Management is committed to addressing this matter and plans to formalize its existing information security practices into a written information security program that is appropriate to the size, complexity, and risk profile of the organization. Management expects to complete the development and implementation of the written program during the upcoming fiscal year. Management believes that this condition does not reflect a failure to safeguard information, but rather a documentation gap that will be remedied through the actions described above.
Management agrees with the finding and has indicated that corrective actions will be implemented to improve monitoring and timeliness of R2T4 returns. Management’s corrective action plan is included in the accompanying schedule.
Management agrees with the finding and has indicated that corrective actions will be implemented to improve monitoring and timeliness of R2T4 returns. Management’s corrective action plan is included in the accompanying schedule.
Finding Number: 2025-003; Planned Corrective Action:Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client HUD-50058 reports are completed accurately. A...
Finding Number: 2025-003; Planned Corrective Action:Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client HUD-50058 reports are completed accurately. Anticipated Completion Date: 6/30/26; Responsible Contact Person: Kristen Runion, HCV Supervisor
Finding Number: 2025-002; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client files contain documentation ensuring complia...
Finding Number: 2025-002; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client files contain documentation ensuring compliance with Rent Reasonableness requirements. Anticipated Completion Date: 6/30/26; Responsible Contact Person: Kristen Runion, HCV Supervisor
Finding Number: 2025-001; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all clients complete an annual family income reexaminat...
Finding Number: 2025-001; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all clients complete an annual family income reexamination in accordance with Eligibility, Reporting, and Housing Assistance Payment requirements. Anticipated Completion Date: 6/30/26; Responsible Contact Person: Kristen Runion, HCV Supervisor
Management Response The University concurs with this finding. Management has initiated a review of all relevant institutional academic calendars to ensure that the correct payment period start and end dates are accurately configured within the Colleague system. The Spring 2025 withdrawal population ...
Management Response The University concurs with this finding. Management has initiated a review of all relevant institutional academic calendars to ensure that the correct payment period start and end dates are accurately configured within the Colleague system. The Spring 2025 withdrawal population is being reviewed to determine whether additional R2T4 recalculations and returns of Title IV funds are required. Necessary corrections will be processed promptly. Going forward, the University will implement procedures to verify that system-configured term dates agree to the officially approved academic calendar prior to each academic term to ensure compliance with federal R2T4 requirements. Corrective Action The University is currently reviewing all R2T4 calculations for the Spring 2025 withdrawal population to ensure calculations were accurate. Necessary corrections will be processed promptly. The University is implementing procedures to verify that system-configured term dates agree to the officially approved academic calendar. The procedures include a review and signoff process to ensure multiple individuals review the information for accuracy. Contact Person Responsible Name – Justin Pichey Title – Director of Financial Aid Phone – 410-532-5735 Email - jpichey@ndm.edu Anticipated Completion Date – April 30, 2026
Management Response The University concurs with this finding. Management has reviewed its processes for monitoring and issuing Title IV credit balance refunds and has implemented procedures to ensure refunds are processed within the required 14-day timeframe. The Financial Aid and Student Accounts o...
Management Response The University concurs with this finding. Management has reviewed its processes for monitoring and issuing Title IV credit balance refunds and has implemented procedures to ensure refunds are processed within the required 14-day timeframe. The Financial Aid and Student Accounts offices will review credit balance reports on a regular basis to identify students eligible for refunds and confirm timely disbursement. In addition, staff have been reminded of federal requirements related to credit balance refunds. Management will monitor this process periodically to ensure ongoing compliance. Corrective Action The University reviewed the federal requirements for refunds with applicable members of the Business Office and Financial Aid departments to ensure a thorough understanding of the refund rules. The University enhanced its weekly credit balance review process to require explicit review by the Controller and Director of Financial Aid if uncertainty exists on whether a student is eligible for a refund. This review must be completed within the 14 day period with either the refund issued or the loan removed from the student’s account. Contact Person Responsible Name – Richard Jones Title – Controller Phone – 410-532-5367 Email – rjones13@ndm.edu Anticipated Completion Date – April 30, 2026
Management Response The University concurs with this finding and has implemented corrective actions to prevent recurrence. The entrance counseling loan processing rule parameters within the Colleague financial aid module have been updated to prevent loan authorization and disbursement if entrance co...
Management Response The University concurs with this finding and has implemented corrective actions to prevent recurrence. The entrance counseling loan processing rule parameters within the Colleague financial aid module have been updated to prevent loan authorization and disbursement if entrance counseling has not been received and posted to the student's loan record. The system update was implemented in February 2026. In addition, the University reviewed loans processed during the affected period to confirm no additional instances of noncompliance occurred. Financial aid staff have been reminded of federal entrance counseling requirements, and management will periodically monitor system controls to ensure continued compliance. Corrective Action In February 2026, the University updated the entrance counseling loan processing rule parameters within the Colleague financial aid module. From February 2026 forward, the rule parameters would prevent a loan from disbursing if the entrance counseling was not performed. The University reviewed loans processed during the period July 2024 – Feb 2026 to ensure there were no additional loans processed without entrance counseling. Contact Person Responsible Name – Justin Pichey Title – Director of Financial Aid Phone – 410-532-5735 Email - jpichey@ndm.edu Anticipated Completion Date – March 31, 2026
Condition: The change in student status for 1 of the 25 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. However, these students were ultimately reported to the NSLDS. Corrective Action Planne...
Condition: The change in student status for 1 of the 25 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. However, these students were ultimately reported to the NSLDS. Corrective Action Planned: The College will implement a secondary review process to ensure that all enrollment updates are through the National Student Clearinghouse within the required timeframe. Name(s) of Contact Person(s) Responsible for Corrective Action Kim Bell, Director of Financial Aid & Compliance Anticipated Completion Date: May 1, 2026
Finding No. 2025-001 – Significant Deficiency and Noncompliance: Reporting Corrective Action The corrective action that will be taken is that Enrollment Information and Status Changes will be reported timely to NSLDS. The following will support this effort: 1. Address Systematic Issues 2. Enhance St...
Finding No. 2025-001 – Significant Deficiency and Noncompliance: Reporting Corrective Action The corrective action that will be taken is that Enrollment Information and Status Changes will be reported timely to NSLDS. The following will support this effort: 1. Address Systematic Issues 2. Enhance Staff Training 3. Implement Regular Monitoring and Auditing Persons Responsible for Corrective Action The corrective action plan will be completed by Corry Unis, Vice President for Enrollment Management and Diana Draper, Executive Director of Financial Aid. Anticipated Completion Date: May 31, 2026 The University has already reported 12 of the 21 students to NSLDS. The University will update the enrollment reporting to NSLDS for the remaining 9 students impacted. The University will determine the principal cause of the discrepancy and implement a combination of controls, monitoring, and training to ensure accuracy and timeliness of future reporting.
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of mont...
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of monthly audits performed by service line leaders will be reported to senior leadership. An internal audit will be done by the compliance team and presented to leadership on a quarterly basis. All appropriate admitting staff will go through training to reinforce our slide process and review procedures for all FQHC services.
Grant salaries and purchase orders will be reviewed for proper accounting. Monthly review with the grant coordinator and the business office will occur to verify appropriate charges.
Grant salaries and purchase orders will be reviewed for proper accounting. Monthly review with the grant coordinator and the business office will occur to verify appropriate charges.
The auditor has confirmed in the ACFR that we have worked with the software provider and identified the issue with the edit check worksheets not correctly reporting meals on a daily basis. The software has been adjusted.
The auditor has confirmed in the ACFR that we have worked with the software provider and identified the issue with the edit check worksheets not correctly reporting meals on a daily basis. The software has been adjusted.
Finding 1205435 (2025-001)
Material Weakness 2025
Department of Treasury Federal Financial Assistance Listing # 21.027 Department of Health and Human Services Federal Financial Assistance Listing #93.493 Procurement, Suspension & Debarment Significant Deficiency in Internal Control over Compliance and Compliance Finding Summary: Our testing over pr...
Department of Treasury Federal Financial Assistance Listing # 21.027 Department of Health and Human Services Federal Financial Assistance Listing #93.493 Procurement, Suspension & Debarment Significant Deficiency in Internal Control over Compliance and Compliance Finding Summary: Our testing over procurement suspension and debarment identified two contracts over $25,000 where some contract provisions required by Uniform Guidance were not included. Responsible Individuals: Jamie Schaefer, John Neth Corrective Action Plan: The organization will review and strengthen the controls surrounding procurement, suspension, and debarment. The Organization will develop a Required Contract Provision Checklist/Reference Sheet that summarizes the requirements in 2 CFR § 200 Appendix II that will be utilized during the grant contract review. Anticipated Completion Date: June 30, 2026
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