Corrective Action Plans

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Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and acknowledges the difference between the auditor’s calculations and what was determined as the varia...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and acknowledges the difference between the auditor’s calculations and what was determined as the variance of R2T4. To ensure full compliance with federal Return to Title IV (R2T4) requirements and to strengthen institutional oversight, Shaw University will implement enhanced processes designed to improve accuracy, documentation, and accountability. Each R2T4 calculation will undergo a dual review process in which one Financial Aid team member completes the calculation and a second independently verifies it before any returns are processed. The University will also maintain comprehensive documentation and audit trail for all R2T4 files, including withdrawal documentation, calculation worksheets, COD records, disbursement summaries, and proof of timely returns, stored systematically to support audit readiness and internal review. To reinforce oversight, management will reconcile internal Financial Aid records with the Business Office and COD on a scheduled basis, conduct monthly or biweekly reconciliations for Pell Grants, Direct Loans, and campus-based funds, and review open balances and disbursement records before posting or adjusting aid. Financial Aid staff will continue to receive annual and periodic training on R2T4 regulations, updated federal guidance, and internal process revisions to ensure consistent application of rules. Additionally, management will conduct periodic internal audits of R2T4 files to identify potential issues proactively and respond with timely corrective measures. These strengthened procedures will ensure that future R2T4 calculations are accurate, fully documented, and completed within federally required timeframes, thereby maintaining strong compliance, reinforcing internal controls, and meeting all expectations for federal oversight. Anticipated Completion Date: April 30, 2026
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the findings. Shaw University acknowledges the findings regarding variances between institutional records and the a...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the findings. Shaw University acknowledges the findings regarding variances between institutional records and the amounts reported on the FISAP, as well as the delay in submitting corrections by the required deadline. The variances were due to insufficient reconciliation between the University’s records and the FISAP prior to submission. In addition, controls were not adequate to ensure that identified discrepancies were corrected within the required timeframe. The University has since completed a full reconciliation of the FISAP, and further corrections will be made. To prevent recurrence, the University has implemented procedures requiring a formal reconciliation of supporting records to the FISAP prior to submission, along with enhanced review and approval controls to ensure accuracy and timely reporting. Management will continue to monitor this process to ensure ongoing compliance. Anticipated Completion Date: April 30, 2026
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and will provide professional justification for the students identified in the audit testing; however, ...
Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding and will provide professional justification for the students identified in the audit testing; however, to strengthen internal controls and prevent potential over awards, the Financial Aid Office will enhance cross departmental communication through routine reconciliation meetings and real time reporting of enrollment, housing, scholarship, and waiver changes, implement a double review process in which an assigned counselor and secondary counselor verify aid packages against COA and financial need before disbursement, and provide annual staff training on need analysis, COA construction, Title IV over award regulations (34 CFR 673.5), and proper use of SIS tools to identify conflicts, ensuring stronger compliance and proactive prevention of award discrepancies. Anticipated Completion Date: April 30, 2026
Name of Responsible Individual: Vice President of Financial Operations/CFO (Michelle Lane) Corrective Action: The University concurs with the findings. Shaw University acknowledges that this finding is a repeat condition related to excess cash balances for Pell Grant, Direct Loan, and FSEOG funds no...
Name of Responsible Individual: Vice President of Financial Operations/CFO (Michelle Lane) Corrective Action: The University concurs with the findings. Shaw University acknowledges that this finding is a repeat condition related to excess cash balances for Pell Grant, Direct Loan, and FSEOG funds not being eliminated within the required seven business days. Management has determined that prior corrective actions were not sufficiently formalized or consistently executed, particularly with respect to reconciliation and monitoring controls. Since that time, the University has strengthened its internal controls over Title IV cash management. A formal monthly reconciliation between G5 drawdowns and the general ledger has been implemented to ensure excess cash balances are identified and resolved timely. In addition, procedures have been revised to limit drawdowns to actual or immediate disbursement needs, and monitoring controls have been established to ensure compliance with the seven-business-day requirement. Management will continue to monitor these processes to ensure ongoing compliance with federal cash management regulations. Anticipated Completion Date: June 30, 2026
2025-001 – Internal Control over Compliance and Compliance with Reporting Contact Name: Bryant Davis Position: Controller Telephone Number: (202) 796 2500 Corrective Action Plan – Management will continue to work with Federal agencies to resolve any grants that a FAIN was not issued. Estimated Compl...
2025-001 – Internal Control over Compliance and Compliance with Reporting Contact Name: Bryant Davis Position: Controller Telephone Number: (202) 796 2500 Corrective Action Plan – Management will continue to work with Federal agencies to resolve any grants that a FAIN was not issued. Estimated Completion – September 30, 2026
Finding Number: 2025-103 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Enforcing secure system access protocols, including multi-factor authentication The institution will implement multi-factor authentication (MFA) across all financial a...
Finding Number: 2025-103 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Enforcing secure system access protocols, including multi-factor authentication The institution will implement multi-factor authentication (MFA) across all financial aid and student information systems to: ● Protect Title IV data from unauthorized access ● Align with federal information security expectations ● Ensure compliance with institutional cybersecurity policies Anticipated Completion Date: 8/31/2026 Responsible Contact Person: Angela Reese
Finding Number: 2025-102 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Generating automated alerts to ensure compliance with federal return-of-funds deadlines To ensure compliance with 34 CFR § 668.22(j): ● The institution will utilize sy...
Finding Number: 2025-102 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Generating automated alerts to ensure compliance with federal return-of-funds deadlines To ensure compliance with 34 CFR § 668.22(j): ● The institution will utilize system-generated alerts to track all R2T4 deadlines ● Staff will follow standardized procedures aligned with federal timelines ● Supervisory review will be required prior to final processing of all returns Anticipated Completion Date: 8/31/2026 Responsible Contact Person: Angela Reese
Finding Number: 2025-101 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Tracking and documenting R2T4 calculations, including secondary review and approval Tom P. Haney Technical College will implement systemic and procedural corrective ac...
Finding Number: 2025-101 The deficiencies resulted from the absence of a comprehensive, system-based control structure capable of: ● Tracking and documenting R2T4 calculations, including secondary review and approval Tom P. Haney Technical College will implement systemic and procedural corrective actions designed to ensure full compliance with Title IV requirements. The institution will procure and implement the Point-of-Sale (POS) module within the FOCUS School Software system to establish automated internal controls. The system will: ● Require documented review and approval workflows for all R2T4 calculations ● Maintain electronic audit trails for all transactions and approvals ● Provide automated notifications and deadline tracking to ensure timely return of funds ● Generate compliance reports for ongoing monitoring The Financial Aid Office will revise and formalize written policies to include: ● R2T4 calculation, review, and approval procedures ● Timelines for return of funds ● System access and authentication requirements All policies will be maintained in accordance with federal recordkeeping requirements under 34 CFR § 668.24. All financial aid and relevant administrative staff will receive training on: ● R2T4 regulatory requirements ● Use of the FOCUS POS system ● Updated institutional policies and procedures Training will be documented and retained for audit purposes. Anticipated Completion Date: 8/31/2026 Responsible Contact Person: Angela Reese
The District acknowledges the audit finding related to documentation of suspension and debarment verification for vendors participating in federally funded programs. While no vendors reviewed were suspended or debarred and no questioned costs were identified, the District agrees that formal document...
The District acknowledges the audit finding related to documentation of suspension and debarment verification for vendors participating in federally funded programs. While no vendors reviewed were suspended or debarred and no questioned costs were identified, the District agrees that formal documentation of this verification should be maintained in the project file. To address this finding, the District has prepared a Standard Operating Procedure titled “Procedure for Debarment Verification for Federally Funded Contracts.” The procedure requires that at the time of contract review for federally funded contracts, prior to contract award, Finance and Business Services staff perform a search in SAM.gov to verify the contractor is not debarred or suspended from receiving federal funds. The result of the debarment search will be saved in the Finance and Business services project files. If the contractor is not registered with SAM.gov, a signed Non-Debarment Certification Form will be obtained from the selected vendor by the Project Manager prior to contract execution. The signed certification form will be saved in the Project Manager’s files along with the executed contract. The District is in the process of reviewing and documenting the debarment search for all vendors who received federal funding under this program. While the comprehensive review is in progress, all requests for federal funds will have the debarment search documentation verified before the request is submitted.
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 40 nonpayroll transactions, we...
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 40 nonpayroll transactions, we found one instance of an unallowable cost for a late fee charged to the grant and 2 instances of transactions recognized in the incorrect fiscal year. Additionally, 1 out of 9 payroll transactions were incorrectly allocated resulting in the understatement of payroll charged to the grant. Recommendation: Amend NBHP’s policies and procedures to include independent review of allowability of cost and payroll allocations. Planned corrective action: NBHP will modify its policies and procedures to include independent review of transaction for allowability and accuracy. Responsible officer: Lisa Albert, Executive Director. Estimated completion date: April 30, 2026.
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 1 out of 6 vendors subject to ...
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #: 21.027, Contract #: 220163. Condition and context: In testing 1 out of 6 vendors subject to procurement, NBHP had not verified and documented that the Houston Health Department was not suspended or disbarred. Recommendation: Amend the procurement policy to require verification that person or organization is not suspended or disbarred. Planned corrective action: NBHP will modify its procurement policy to include verification that persons or organizations are not suspended or disbarred. Responsible officer: Lisa Albert, Executive Director. Estimated completion date: April 30, 2026.
Noncompliance with Reporting Requirements
Noncompliance with Reporting Requirements
Criteria: The Organization’s major department agreements carry with it certain periodic reporting requirements that are due at various points following the close of each month, quarter, or reporting period.
Criteria: The Organization’s major department agreements carry with it certain periodic reporting requirements that are due at various points following the close of each month, quarter, or reporting period.
Condition: We noted multiple instances in which required monthly performance measures and narrative reports were either submitted after the stated deadline or lacked support to indicate when or if a report was completed and submitted.
Condition: We noted multiple instances in which required monthly performance measures and narrative reports were either submitted after the stated deadline or lacked support to indicate when or if a report was completed and submitted.
Known Questioned Costs: None
Known Questioned Costs: None
Likely Questioned Costs: None
Likely Questioned Costs: None
Context: As part of our testing the monthly reporting requirements for ALN #93.959, we noted for the Shelter program two instances in which a required monthly performance measures and narrative report was submitted after the required deadline. For both the Detox and Extended Care programs, we noted ...
Context: As part of our testing the monthly reporting requirements for ALN #93.959, we noted for the Shelter program two instances in which a required monthly performance measures and narrative report was submitted after the required deadline. For both the Detox and Extended Care programs, we noted fourteen instances, and assumed an additional ten instances, in which a required monthly performance measures and narrative report lacked the support indicating when a report was filed, or whether the reports were completed on a monthly basis. Per discussions with the client, specific to reports with no indication as to whether the report was submitted, the cumulative fiscal year report was provided to support the annual completion of the report; however, given staff turnover, monthly submissions were unable to be located for both the Detox and Extended Care programs.
Cause: Management oversight.
Cause: Management oversight.
Effect: Untimely filing of reports could result in delays in future funding or funds received being returned to the grantor.
Effect: Untimely filing of reports could result in delays in future funding or funds received being returned to the grantor.
Repeat Finding: Yes
Repeat Finding: Yes
Recommendation: We encourage the Organization to continue its efforts to ensure that all contract reports are submitted timely in the future, and support of such submissions be maintained in a central location easily accessible by all authorized users.
Recommendation: We encourage the Organization to continue its efforts to ensure that all contract reports are submitted timely in the future, and support of such submissions be maintained in a central location easily accessible by all authorized users.
Views of responsible officials and planned corrective action: We are in agreement with the finding. Management is in the process of creating an updated process/system to ensure compliance with this requirement moving forward.
Views of responsible officials and planned corrective action: We are in agreement with the finding. Management is in the process of creating an updated process/system to ensure compliance with this requirement moving forward.
2025-001. Allowable Costs/Cost Principles United States Department of Education, Passed Through New York State, Department of Education: Title I Grants to Local Educational Agencies ALN: 84.010A Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for...
2025-001. Allowable Costs/Cost Principles United States Department of Education, Passed Through New York State, Department of Education: Title I Grants to Local Educational Agencies ALN: 84.010A Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee’s compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PAR) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District prepared periodic certification equivalents, but it did not comply with the documentation standards prescribed by Subpart E, 2 CFR §200.430; the amount of one employee’s actual payroll charged to the Title I federal award was less than the allocation percentage on the periodic certification reports that were signed by the employee’s supervisor. Planned Corrective Action: The District will adopt procedures that ensure that appropriate documentation for time and effort will be used to support costs charged to the federal award, and comply with Subpart E, 2 CFR §200.430. Responsible Contact Person: Mr. William Ludeker Assistant Superintendent for Business Lindenhurst Union Free School District 350 Daniel Street Lindenhurst, New York 11757 Anticipated Completion Date: June 30, 2026.
Finding 2025-001 Condition There were 2 invoices out of 40 tested that were incorrectly entered into the Organization’s billing system related to the Rehabilitation Services Vocational Grant program. The Organization erroneously recorded the invoices, and the error was not detected during the Organi...
Finding 2025-001 Condition There were 2 invoices out of 40 tested that were incorrectly entered into the Organization’s billing system related to the Rehabilitation Services Vocational Grant program. The Organization erroneously recorded the invoices, and the error was not detected during the Organization’s daily operations. The sample was not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The process for internal verification will be strengthened by centralizing the internal controls to include one individual responsible for the approval of the pre-bill and one individual responsible for entering the invoice into the internal billing system. This process will be changed from a monthly to a weekly verification. The person responsible for the approval of the pre-bill will review the amounts entered into the internal billing system for accuracy by verifying that all invoices entered match the dollar amount listed on the invoice. Name(s) of Contact Person(s) Responsible for Corrective Action: Abigail Fisch – PA Program Coordinator of OVR, Nicole Brion – Revenue Cycle Management Billing Manager Anticipated Completion Date: September 30, 2025
Finding 1205530 (2025-003)
Material Weakness 2025
Management concurs in part and disagrees in part with this finding. Management has always understood that alcohol purchases may not be charged to a Federal program and are unallowable under Uniform Guidance, and we are committed to ensuring full compliance with federal cost principles. Upon identifi...
Management concurs in part and disagrees in part with this finding. Management has always understood that alcohol purchases may not be charged to a Federal program and are unallowable under Uniform Guidance, and we are committed to ensuring full compliance with federal cost principles. Upon identification of this exception, management initiated corrective measures to reinforce internal controls surrounding expense review and documentation. The accounting staff member did not have the itemized receipt at the time the expense was initially allocated. Had the receipt been available, the unallowable cost would have been identified, and the expense would not have been allocated to program costs. Once the receipt was reviewed, the alcohol purchase was identified as unallowable under Federal programs and allocated correctly to administration costs. To prevent similar issues moving forward, accounting staff have been re-trained on expense documentation and receipt-tracking requirements, with emphasis on ensuring that itemized receipts are obtained and reviewed prior to allocation, reimbursement, or payment. Staff have also been reminded of the importance of validating expenditures against Uniform Guidance allowability requirements as part of their routine review procedures. Management will continue to monitor expense activity to ensure the effectiveness of these reinforced controls. The anticipated completion date for this corrective action is 11/1/2025.
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