Corrective Action Plans

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2025-004: Internal Control over Activities Allowed/Allowable Costs – COVID-19: Education Stabilization Fund Corrective Action: The District acknowledges this finding. Invoices are reviewed by the Administration and Board of Education monthly. Additional reviews by administration will be put into pla...
2025-004: Internal Control over Activities Allowed/Allowable Costs – COVID-19: Education Stabilization Fund Corrective Action: The District acknowledges this finding. Invoices are reviewed by the Administration and Board of Education monthly. Additional reviews by administration will be put into place. The Board of Education shall approve the pay rates annually and appropriate documentation kept. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
2025-003: Internal Control over Eligibility – Child Nutrition Cluster Corrective Action: Acknowledging the lack of controls within the Child Nutrition program's eligibility process, the District has determined that hiring additional staff to resolve this internal control deficiency is not a cost-eff...
2025-003: Internal Control over Eligibility – Child Nutrition Cluster Corrective Action: Acknowledging the lack of controls within the Child Nutrition program's eligibility process, the District has determined that hiring additional staff to resolve this internal control deficiency is not a cost-effective solution. Consequently, the Food Service Director and the Finance Director share the responsibility of reviewing student eligibility forms. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
During testing of the Special Tests and Provisions compliance requirement, the College did not timely and accurately report changes in student enrollment status, including graduation, at both the campus level and academic program level, as required by the U.S. Department of Education. A significant ...
During testing of the Special Tests and Provisions compliance requirement, the College did not timely and accurately report changes in student enrollment status, including graduation, at both the campus level and academic program level, as required by the U.S. Department of Education. A significant pattern observed was that students who graduated were not reported to National Student Loan Data System (NSLDS) as having completed their program before subsequently enrolling in additional coursework. As a result, NSLDS continued to reflect these students as active, rather than completed, at the time new enrollment was reported. This leads to inaccurate federal enrollment records and may affect students’ loan repayment timelines and grace period calculations. Corrective Action: 1. Process Checks Implemented: Our staff that complete reporting for graduation to the National Student Clearinghouse (NSC) will use the NSC error reports to identify students who have graduated in one program but are continuing into another program. They will then manually correct the students’ records via the error resolution process with NSC. This happens within the 60-day window. 2. Correction to Existing Records: The impacted students (762 students from March 2024 to October 2024) have been properly reported manually in NSC by our processors and now display with proper graduation information from programs that they have completed. 3. Staff Training: A meeting was held with the NSC processing staff to ensure that we are reporting within 30 days of the receipt of final grades/system graduation processing and correcting error reports received from NSC within 30 days of receipt of such reports. Ongoing Compliance The Registrar’s Office will audit their NSC reported graduates each term moving forward to ensure that any “special” cases of students in multiple programs are reporting correctly when one program is completed.
During compliance testing, the Auditor identified—and we concur—that a student received a Subsidized Direct Loan that resulted in an over award. Upon further internal review, we determined that the student was an in-county, dependent student whose Parent PLUS Loan had been denied. In accordance with...
During compliance testing, the Auditor identified—and we concur—that a student received a Subsidized Direct Loan that resulted in an over award. Upon further internal review, we determined that the student was an in-county, dependent student whose Parent PLUS Loan had been denied. In accordance with federal regulations, a PLUS denial provides eligibility for additional Federal Direct Unsubsidized Loan funds. When the loan was processed, the over award occurred when the Independent Student Cost of Attendance (COA) was applied for one semester instead of the Dependent Student COA. Using the incorrect COA budget resulted in awarding the student excess Subsidized Loan eligibility. Corrective Action: 1. System Controls Implemented: A request was submitted to our ITS Department to develop a daily validation report identifying all students who have the “additional unsubsidized” flag in the Colleague system. The report includes the COA used in determining eligibility. By reviewing this report daily, any inaccuracies in cost of attendance for this student population can be identified and corrected prior to origination and disbursement. 2. Verification of Scope: The report was run for the 2024–2025 academic year. The student described above was the only case identified, confirming that this was an isolated error. 3. Correction to the Award: The student’s Direct Loans were reallocated to remain compliant with federal regulations and the student was notified of the loan change. 4. Staff Training and Communication: A meeting was held with all loan processors to review this finding and reinforce that the Dependent Student COA must be used when processing additional unsubsidized eligibility for dependent students whose parents are denied a PLUS Loan. Ongoing Compliance The Financial Aid Office will maintain the daily validation report as an internal control measure to prevent recurrence. Staff will continue to be trained and monitored for adherence to federal and institutional policy regarding loan eligibility and COA assignments.
Recommendation: We recommend the District review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Action taken in response to finding: During the 2024-2025 audit, two enrollment records were reported late to NSLDS ...
Recommendation: We recommend the District review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Action taken in response to finding: During the 2024-2025 audit, two enrollment records were reported late to NSLDS in October 2024. The late reporting occurred prior to the implementation of the corrective action plan developed during the 2023–2024 audit period. The previously identified cause was timing gaps between Clearinghouse file submission and NSLDS processing. Corrective Action Taken: The corrective action plan from the 2023–2024 audit period was fully implemented as of Spring 2025 and has addressed the root cause of the late reporting. Actions implemented include: • Reviewed and documented enrollment reporting timelines from Clearinghouse submission through NSLDS posting. • Established consistent file submission schedules aligned with NSLDS reporting deadlines. • Formalized communication and escalation procedures with the Clearinghouse and NSLDS, including designated points of contact. • Updated internal policies and procedures to reflect revised reporting timelines. • Provided training to staff responsible for enrollment reporting, emphasizing timeliness and compliance requirements. • Implemented monitoring controls to track file submission, acceptance, and processing by NSLDS. The 2023-2024 audit corrective action plan was successfully implemented in Spring 2025. Since implementation, no additional late enrollment reporting instances have occurred. Moving forward, it is expected that enrollment reporting to NSLDS will be timely and compliant with federal requirements, supported by documented procedures and ongoing monitoring controls. Name of the contact person responsible for corrective action: Dr. Kristina Martinez, Acting Dean of Enrollment Services Planned completion date for corrective action plan: June 30, 2026
Recommendation: We recommend the District continue to enhance and consistently apply R2T4 procedures by providing ongoing training to staff responsible for R2T4 calculations and by continuing with additional reviews and quality control measures to ensure accuracy and compliance. Action taken in resp...
Recommendation: We recommend the District continue to enhance and consistently apply R2T4 procedures by providing ongoing training to staff responsible for R2T4 calculations and by continuing with additional reviews and quality control measures to ensure accuracy and compliance. Action taken in response to finding: The District acknowledges the importance of compliance with Return to Title IV (R2T4) requirements. The repeat finding cited in the subsequent audit relates to files processed prior to implementation of the corrective action plan. Since implementation, the District has not identified any new R2T4 errors or compliance issues. Action taken in response to finding: 1. Prior-Year File Remediation • Recalculated R2T4 amounts for affected students. • Returned required funds to the U.S. Department of Education. 2. Oversight and Review Controls • Engaged a NASFAA-certified consultant to review all R2T4 calculations during the 2024–2025 aid year. • Implemented secondary internal review of all R2T4 calculations. 3. Training and Staffing Enhancements • Completed department-wide and R2T4-specific training. • R2T4 staff completed NASFAA R2T4 course series. • An additional Accounting Officer position was added to support R2T4 processing and reconciliation with appropriate system access. 4. Process Improvements • Transitioned to the Department of Education’s R2T4 worksheet in COD. • Established formal coordination with Academic Affairs and the Registrar. • Updated R2T4 training and job aids. 5. Ongoing Monitoring • Management performs periodic internal reviews of R2T4 files. • The District continues to evaluate system and reporting enhancements. Conclusion Although the audit included R2T4 files processed prior to corrective action implementation, the District’s actions have been effective. No new R2T4 issues have been identified since implementation, and controls are in place to ensure ongoing compliance. Name of the contact person responsible for corrective action: David Brown, Acting Director of Financial Aid & Basic Needs Planned completion date for corrective action plan: June 30, 2026
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with...
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with all Medicaid workers, including NC Fast Learning Gateway Training “Supplemental Security Income (SSI) Course”. Proposed Completion Date: June 30, 2026. Certain controls are currently being created and reviewed. Management will continue to monitor the progress of this issues and modify the controls as needed.
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with...
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with all Medicaid workers, including NC Fast Learning Gateway Training “Supplemental Security Income (SSI) Course”. Proposed Completion Date: June 30, 2026. Certain controls are currently being created and reviewed. Management will continue to monitor the progress of this issues and modify the controls as needed.
On a going-forward basis, management will enhance its monitoring of compliance with these requirements to ensure that EIV reports are run earlier than, but not more than 120 days before a tenant’s required annual recertification date.
On a going-forward basis, management will enhance its monitoring of compliance with these requirements to ensure that EIV reports are run earlier than, but not more than 120 days before a tenant’s required annual recertification date.
Finding Number 2025-001. Enrollment Reporting - The College hired a full-time Registrar in December 2025. Upon onboarding, the Registrar will collaborate with the College’s third-party consultant(s) to conduct a comprehensive review and re-evaluation of the enrollment reporting configuration and ass...
Finding Number 2025-001. Enrollment Reporting - The College hired a full-time Registrar in December 2025. Upon onboarding, the Registrar will collaborate with the College’s third-party consultant(s) to conduct a comprehensive review and re-evaluation of the enrollment reporting configuration and associated business processes. This review will ensure alignment with federal reporting requirements and institutional best practices. During this review period, the Registrar and the Financial Aid Office will jointly implement ongoing monitoring procedures to ensure that all students are accurately captured and that enrollment statuses are correctly and timely reported to the National Student Loan Data System (NSLDS). These monitoring controls will remain in place until the enrollment reporting system and processes are fully vetted and validated for compliance. Anticipated Completion Date - February 28, 2026. Responsible Contact Person for Planned Corrective Action: Dominique Colyer, Director of Financial Aid
The District’s Director of Business Affairs conducts reviews of meal counts manually entered into the District’s point of sale system and the CRRS, and verifies the counts entered manually into the CRRS system. These review procedures are acknowledged by initials/signatures.
The District’s Director of Business Affairs conducts reviews of meal counts manually entered into the District’s point of sale system and the CRRS, and verifies the counts entered manually into the CRRS system. These review procedures are acknowledged by initials/signatures.
Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by...
Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by a formula error within the reporting templates. Where possible, we will add automated check figures to the reporting spreadsheets to validate data accuracy and strengthen internal review procedures. Jamie Moore, Accounting Manager, will be responsible for ensuring this is accomplished. The correction action plan will be implemented by September 30, 2026.
Corrective Action Plan Single Audit Finding 2025-001: Internal Controls over Allowable Costs/Activities Plan: The IFA acknowledges the importance of internal controls and appropriate segregation of duties ensuring the review and approval process for Authority financial transactions (i.e., expenditur...
Corrective Action Plan Single Audit Finding 2025-001: Internal Controls over Allowable Costs/Activities Plan: The IFA acknowledges the importance of internal controls and appropriate segregation of duties ensuring the review and approval process for Authority financial transactions (i.e., expenditures applied to corresponding grants are allowable; month-end financial entries; etc.). With recent staff additions, IFA has enhanced its internal control environment by implementing a review/authorization process to ensure the preparation and approval of journal entries (i.e., month-end, etc.) occurs in accordance of established internal controls and appropriate segregation of duties (e.g., month-end journal entries prepared by the IFA SVP-FA are reviewed and approved by the IFA Chief Operating Officer, or appropriate designee). Since manual or adjusting journal entries are information processing activities that carry higher risk, a review of journal entries after posting serve as acceptable verification control in accordance with the United States Government Accountability Office Standards for Internal Control in the Federal Government that helps ensure transactions are appropriate. These post-entry reviews represent an acceptable form of management oversight (Principle 16) and serve as an acceptable validation check (Principle 10) to confirm that entries align with supporting documentation, reconcile with expectations, and aligned with organizational directives. Month Implemented: November 2025 IFA Contact: Ms. Ximena Granda SVP – Finance & Administration xgranda@il-fa.com Office (312) 651-1362
YWCA Delaware, Inc. will implement procedures and policies to enable it to identify the required reporting requirements for federal awards throughout the year and at year end and ensure all reports are filed timely and accurately.
YWCA Delaware, Inc. will implement procedures and policies to enable it to identify the required reporting requirements for federal awards throughout the year and at year end and ensure all reports are filed timely and accurately.
Finding 2025-002: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that key control documentation is retained on file. The payroll file will be approved by either the Superintendent or th...
Finding 2025-002: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that key control documentation is retained on file. The payroll file will be approved by either the Superintendent or the CFO prior to payment, and proof of prior approval will be maintained in the School’s files. The new process began in January 2026. Responsible Party: Kemlyn Williams, Superintendent Dynamic Support Solutions, Contract CFO
Finding 2025-001: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that invoices are approved prior to being paid. Expenses are reviewed and approved through the PO process within the Asc...
Finding 2025-001: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that invoices are approved prior to being paid. Expenses are reviewed and approved through the PO process within the Ascender System. Each request is evaluated for accurate account coding, appropriateness, and compliance with Federal Grant allowable costs (when necessary). Spending and allowable costs are closely monitored on an ongoing basis. Once orders have been placed, products have been received/services rendered, and invoices received, the accounting clerk will prepare documents for the check run. A “check payments” report is provided which lists all transactions for the check run. The “check payments” document clearly displays the vendor, account code, and amount of each transaction. The “check payments” report is approved by Superintendent. Once “check payment” report is approved by Superintendent, the check run will be initiated. Documentation of prior approval will be kept on file. The new process began in March 2025. Responsible Party: Kemlyn Williams, Superintendent Dynamic Support Solutions, Contract CFO
Schedule of Expenditures of Federal Awards (SEFA) Preparation UHMS commits to completing the SF 425/SEFA timely and accurately then providing it for audit. Person responsible: Matthew Solomon
Schedule of Expenditures of Federal Awards (SEFA) Preparation UHMS commits to completing the SF 425/SEFA timely and accurately then providing it for audit. Person responsible: Matthew Solomon
Reconciliations and Material Adjustments UMHS' acting Chief Executive Officer (CEO) was also the Chief Financial Officer (CFO) until October 2025 when a Finance Director was added. The Finance Director has an accounting degree, a master's in business administration (MBA), and is a licensed Certified...
Reconciliations and Material Adjustments UMHS' acting Chief Executive Officer (CEO) was also the Chief Financial Officer (CFO) until October 2025 when a Finance Director was added. The Finance Director has an accounting degree, a master's in business administration (MBA), and is a licensed Certified Public Accountant (CPA) with over 30 years' accounting and management experience. UMHS also retained the Payroll and Fund Accounting Manager who was on leave for 3 months in 2025. A replacement for the Fund Accounting Manager who passed away in February 2026 is also in progress. Many improvements to the Finance department have been implemented Since October 2025 including: a. Establishing department goals focusing on catching up on all required accounting activities including all reconciliations b. Removing the burdensome procurement requisition process when all the required purchase orders (POs) elements are completed and documented allowing more Finance to focus on core financial activities c. Planning for moving purchasing from the Finance department back to Operations to help focus Finance on core accounting activities d. Updating policies e. Drafting (approximately 10) formal and detailed procedures for all key/material activities f. Updating the Cost Allocation Plan g. Improving grant financial information/reports to Program Directors and Managers h. Submitting claims/draws to grantors before payroll is paid out and allocating out indirect (Admin) costs to grants allowing reimbursement through drawdowns/claims 45-60 days earlier for improved cash flow i. Several other changes for improved transparency and tracking Person responsible: Matthew Solomon
The Office of Financial Aid has implemented a formal annual review process to determine whether Golden Gate University should request a waiver of the Federal Work-Study (FWS) expenditure requirement for the upcoming waiver period. Each February, the Associate Director of Financial Aid and the Senior...
The Office of Financial Aid has implemented a formal annual review process to determine whether Golden Gate University should request a waiver of the Federal Work-Study (FWS) expenditure requirement for the upcoming waiver period. Each February, the Associate Director of Financial Aid and the Senior Director of Student Financial Services will evaluate projected spending and decide if a waiver is necessary. If a waiver is required, it will be submitted within the designated deadline, which typically falls between March and April each year.
Recommendation: We recommend management maintain awareness of audit reporting deadlines to ensure timely submission to maintain Single Audit and federal compliance requirements. Management’s Response: The Agency agrees with the finding. Management has assigned the responsibility for monitoring and s...
Recommendation: We recommend management maintain awareness of audit reporting deadlines to ensure timely submission to maintain Single Audit and federal compliance requirements. Management’s Response: The Agency agrees with the finding. Management has assigned the responsibility for monitoring and submitting the DCF and reporting package to specific personnel.
Finding 2025-001 Eligibility - Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Historical documentation on patient eligibility for IHS beneficiary status residing in paper financial files (in use at the time of roll and scroll registration) wi...
Finding 2025-001 Eligibility - Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Historical documentation on patient eligibility for IHS beneficiary status residing in paper financial files (in use at the time of roll and scroll registration) will be scanned in the BMW registration system making them a permanent part of the patients’ electronic health record. Registration staff is requesting beneficiary identification at the time of registration for all patients that do not have it in their EHR. Project is ongoing. Monthly audits of the elements of registration, including documentation of beneficiary status will be conducted to ensure continual compliance. Individual(s) Responsible for Corrective Action Plan Kandy Barlow VP of Health Services 907-442-7385 Anticipated Completion Date: March 31, 2026
Finding 2025-004: Reporting – Owner – Certified Submission Management Response Management agrees with the finding. REAC submission was late because year – end accounting records were not done in time. Corrective Action Plan 1. Establish a Closing Calendar and Compliance Calendar • Year-end data dead...
Finding 2025-004: Reporting – Owner – Certified Submission Management Response Management agrees with the finding. REAC submission was late because year – end accounting records were not done in time. Corrective Action Plan 1. Establish a Closing Calendar and Compliance Calendar • Year-end data deadlines • Dates for draft and final financials • REAC submission due date 2. Coordination with Fee Accountant • Schedule year-end preparation work earlier • Fee Accountant set a deadline for LHA to provide supporting documents IMPLEMENTATION TIMELINE: PRIOR TO NEXT FISCAL YEAR-END.
Finding 2025-003 Replacement Reserves Management Response Management agrees with the finding. Excess deposits, incorrect posting of a reserve transfer and an unapproved withdrawal occurred due to inadequate oversight and incomplete reconciliation procedures. Corrective Action Plan 1. Deposit and Wit...
Finding 2025-003 Replacement Reserves Management Response Management agrees with the finding. Excess deposits, incorrect posting of a reserve transfer and an unapproved withdrawal occurred due to inadequate oversight and incomplete reconciliation procedures. Corrective Action Plan 1. Deposit and Withdrawal Controls • LHA has made an invoice for each month deposit • All withdrawals will be required written HUD approval and retention of documentation in a secured file 2. Monthly Reserve Account Verification • Review all deposit and withdrawal activity • Confirm no transfers were made to other program reserve accounts • Immediately request return of incorrectly transferred funds 3. HUD Follow-up • Contact HUD to determine required corrective steps for the unapproved withdrawal. IMPLEMENTATION TIMELINE: WITHIN 60 DAYS
Audit Finding 2025-002 Special Tests and Provisions Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Timely Reporting Errors:  The University was still reporting students from the School of Business and Society and the School of Education under a different branch cod...
Audit Finding 2025-002 Special Tests and Provisions Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Timely Reporting Errors:  The University was still reporting students from the School of Business and Society and the School of Education under a different branch code (001322-80) in its third-party provider (National Student Clearinghouse), even though that branch code did not exist in the National Student Loan Data System (NSLDS). This was an artifact of a previous academic structure and calendar. With the help of the provider, this branch has been consolidated with the main branch (001322-00) and all programs on the same calendar are now reported simultaneously helping to ensure that all students are recorded.  Upon acceptance of the submitted files to NSLDS, the Registrar’s Office will compare the roster in NSLDS to that of the submitted roster and the current census roster to identify and correct discrepancies either in the student information system or NSLDS. Availability of these types of reports in NSLDS is still being determined. Contact Person Responsible for Corrective Action: Eric Maczka, University Registrar and Director of Institutional Research, eric_maczka@redlands.edu, 909-748-8333 Anticipated Completion Date: March 15, 2026
Audit Finding 2025-001 Special Tests and Provisions Return of Title IV Funding (R2T4): Significant Deficiency in Internal Control over Compliance Student Financial Services has strengthened the current R2T4 calendar set up and calculation review process. An additional administrator in SFS reviews ea...
Audit Finding 2025-001 Special Tests and Provisions Return of Title IV Funding (R2T4): Significant Deficiency in Internal Control over Compliance Student Financial Services has strengthened the current R2T4 calendar set up and calculation review process. An additional administrator in SFS reviews each calendar created in COD to specifically check and document the total number of days in the payment period including scheduled breaks. In addition, University calendars have now been approved for several years in advance so this will prevent late date changes. At the time this student was identified, all students in this program were reviewed for R2T4s and it was confirmed that this is the only student in the program who withdrew and required an R2T4 calculation. The R2T4 was reprocessed with the corrected number of days. The student was contacted about the error in the calculation and informed of their eligibility for an additional $71 in Direct Loan. The student chose not to increase their loan by the additional $71 so no adjustments were made to the student record or to COD. Contact person responsible for Corrective Action: Alisha Aguilar, Associate Vice President of Student Financial Services and Military & Veteran Services alisha_aguilar@redlands.edu, 909-748-8047 Anticipated Completion Date: January 1, 2026
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