Corrective Action Plans

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West Hills Community College District and Lemoore College acknowledge the audit finding related to enrollment reporting to the National Student Loan Data System (NSLDS). While no questioned costs were identified, the District recognizes the importance of accurate, timely, and complete enrollment rep...
West Hills Community College District and Lemoore College acknowledge the audit finding related to enrollment reporting to the National Student Loan Data System (NSLDS). While no questioned costs were identified, the District recognizes the importance of accurate, timely, and complete enrollment reporting and is committed to strengthening internal controls to ensure full compliance with U.S. Department of Educa on requirements.
The District concurs with the audit finding. The error occurred in the context of courses offered in modules, which are subject to unique federal calculation requirements. To address this finding and strengthen internal controls over R2T4 calculations for modular coursework, Lemoore College will imp...
The District concurs with the audit finding. The error occurred in the context of courses offered in modules, which are subject to unique federal calculation requirements. To address this finding and strengthen internal controls over R2T4 calculations for modular coursework, Lemoore College will implement the following corrective actions: 1. System-Based Calculation Tool Development Lemoore College will work with the District’s IT department to develop a tool that accurately calculates the percentage of the term completed for students enrolled in courses offered in modules. This tool will be designed to align with applicable federal R2T4 requirements and reduce reliance on manual calculations. 2. Interim Manual Calculation Controls Until the system-based solution is implemented, Lemoore College will implement enhanced review procedures for all R2T4 calculations involving modular coursework, including documented secondary review of the withdrawal date, module dates, and percentage of term completed. 3. Procedure Documentation and Staff Guidance Lemoore College will update internal procedures and provide targeted guidance to Financial Aid staff regarding R2T4 calculations for modular courses, including documentation standards and review expectations. 4. Ongoing Monitoring Supervisory monitoring and periodic spot checks will be conducted to ensure the continued accuracy of R2T4 calculations involving modular coursework.
January 27, 2026 Aldrich CPAs + Advisors LLP 7676 Hazard Center Drive, Suite 550 San Diego, CA 92108 RE: Corrective Action Plan Dear Aldrich, The following are responses to the finding identified in Union of Pan Asian Communities (UPAC) audit for the year ended June 30, 2025: 1) Finding 2025-001 a. ...
January 27, 2026 Aldrich CPAs + Advisors LLP 7676 Hazard Center Drive, Suite 550 San Diego, CA 92108 RE: Corrective Action Plan Dear Aldrich, The following are responses to the finding identified in Union of Pan Asian Communities (UPAC) audit for the year ended June 30, 2025: 1) Finding 2025-001 a. Program Information: 93.778 Medicaid Cluster – Medical Assistance Program, Pass-Through Award #567787 b. Criteria: In accordance with 2 CFR 200.329, non-Federal entities must submit performance reports at the interval required by the Federal awarding agency or pass-through entity no later than the specified due date. If a justified request is submitted by a non-Federal entity, the Federal agency may extend the due date for any performance report. c. Condition: During our audit, we identified one quarterly status report that was submitted to the Contracting Officer’s Representative (COR) after the stated due date. Response: UPAC has put in place a system of reminders and deadline review with program managers and administrative staff to ensure deadlines for contract reporting due dates are calendared and scheduled in advance. Contact persons responsible for corrective action: 1) Sarah Ferry, Chief Financial Officer 2) Courtney Boatman, Vice President of Addiction Treatment and Recovery Services Completion date: Additional internal control procedure noted above will be effective immediately. Sincerely, Wendy Urushima-Conn Chief Executive Officer Union of Pan Asian Communities
Recommendation: Management should ensure that employees are aware of the jobs they are working on as they log their time, and supervisors should include this as part of their review process. When adjustments to correct errors are necessary, management should document the reason for the correction as...
Recommendation: Management should ensure that employees are aware of the jobs they are working on as they log their time, and supervisors should include this as part of their review process. When adjustments to correct errors are necessary, management should document the reason for the correction as well as review of that correction. The accounting department should record the adjustments in the general ledger through a journal entry. Action Taken: The Finance and Human Resources departments are implementing enhancements to existing payroll allocation processes, including additional training and guidance to employees and supervisors to reinforce proper timekeeping and project coding in accordance with established policy. Management will also implement formal control requiring documented review and approval of payroll allocation adjustments. All approved adjustments will be recorded in the general ledger through journal entries prepared and reviewed in accordance with established accounting procedures. Anticipated completion date: June 30, 2026
Recommendation: We recommend the Organization develop and implement a formal SEFA preparation policy that includes: - A centralized tracking system for all federal and pass-through awards, including subaward documentation - Review of the draft SEFA by another individual with knowledge of Federal rep...
Recommendation: We recommend the Organization develop and implement a formal SEFA preparation policy that includes: - A centralized tracking system for all federal and pass-through awards, including subaward documentation - Review of the draft SEFA by another individual with knowledge of Federal reporting requirements and grants received. Additional training on Uniform Guidance requirements would also be beneficial Action Taken: Accounting will implement a formal SEFA preparation process that includes the development of a centralized schedule to track direct and pass-through federal funding sources. The schedule will incorporate key data fields necessary to support SEFA reporting and compliance, including identification of pass-through entities and applicable expenditure thresholds. A formal review process will be implemented to provide for appropriate separation of duties, with one individual responsible for preparation and a separate individual responsible for review and approval.
#2025-006: Written Uniform Guidance Policies Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City is currently developing written policies for activities allowed or unallowed, allowable costs/cost principles, and procurement and suspension and debarment in accord...
#2025-006: Written Uniform Guidance Policies Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City is currently developing written policies for activities allowed or unallowed, allowable costs/cost principles, and procurement and suspension and debarment in accordance with Uniform Guidance. Anticipated Completion Date: Fiscal year 2026.
#2025-002: Audit Adjustments Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The Clerk/Treasurer has reviewed the recommendations, and such will be implemented as appropriate throughout the year and ahead of the fiscal year 2026 audit. Anticipated Completion Date: On...
#2025-002: Audit Adjustments Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The Clerk/Treasurer has reviewed the recommendations, and such will be implemented as appropriate throughout the year and ahead of the fiscal year 2026 audit. Anticipated Completion Date: Ongoing
#2025-001: Financial Statement and SEFA Preparation Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: Management of the City has reviewed the financial statements and schedule of expenditures of federal awards prepared by Ketel Thorstenson, LLP. The financial statement...
#2025-001: Financial Statement and SEFA Preparation Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: Management of the City has reviewed the financial statements and schedule of expenditures of federal awards prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the City. Management and City Council has been given adequate opportunity to ask questions regarding the financials statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Anticipated Completion Date: Ongoing
#2025-005: Grant Tracking Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City will develop a process to agree actual expenditures incurred to the general ledger before requesting reimbursement. Anticipated Completion Date: Fiscal year 2026.
#2025-005: Grant Tracking Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City will develop a process to agree actual expenditures incurred to the general ledger before requesting reimbursement. Anticipated Completion Date: Fiscal year 2026.
2025-002 Net Cash Resources - Child Nutrition Cluster (ALN # 10.553/10.555/10.559) Corrective Action Plan School District management agrees with condition, cause, and recommendation. With this overage, the School District has purchased some new equipment for the cafeteria. Since the School District ...
2025-002 Net Cash Resources - Child Nutrition Cluster (ALN # 10.553/10.555/10.559) Corrective Action Plan School District management agrees with condition, cause, and recommendation. With this overage, the School District has purchased some new equipment for the cafeteria. Since the School District is CEP, there is no option to change the revenue. The School District will continue upgrading the kitchens with the excess. Expected Correction Date: June 30, 2026 Contact: Kathy Rote, School Business Administrator (607) 565-2841 15 Frederick St. Waverly, NY 14892
Corrective Action: As of September 30, 2024, SHN has implemented strengthened internal control procedures over reporting. Under the updated process, the accountant prepares all reimbursement requests, and the Consulting Controller performs a supervisory review and formal approval prior to submission...
Corrective Action: As of September 30, 2024, SHN has implemented strengthened internal control procedures over reporting. Under the updated process, the accountant prepares all reimbursement requests, and the Consulting Controller performs a supervisory review and formal approval prior to submission. This review ensures accuracy, completeness, and compliance with reporting requirements before the accountant submits the final reports to the funding agency. Proposed completion date: Management will implement the above procedures immediately.
Corrective Action: Beginning in FY 2026, the Partnerships and Programs Department will formalize and implement procedures within its subrecipient monitoring processes to ensure that all subrecipients subject to the Single Audit requirement are identified and verified as compliant. These procedures w...
Corrective Action: Beginning in FY 2026, the Partnerships and Programs Department will formalize and implement procedures within its subrecipient monitoring processes to ensure that all subrecipients subject to the Single Audit requirement are identified and verified as compliant. These procedures will include annual review of subrecipient expenditures, confirmation of audit submissions when applicable, and documentation of all monitoring activities to ensure ongoing adherence to Uniform Guidance requirements. Proposed completion date: Management will implement the above procedures immediately.
Corrective Action: SHN will develop a comprehensive Federal Grants Management Policy Manual, including procurement-related procedures that fully align with the requirements of Uniform Guidance (2 CFR 200.320). The draft manual and related procedures will be reviewed by an external Federal Grants Man...
Corrective Action: SHN will develop a comprehensive Federal Grants Management Policy Manual, including procurement-related procedures that fully align with the requirements of Uniform Guidance (2 CFR 200.320). The draft manual and related procedures will be reviewed by an external Federal Grants Management Specialist to ensure accuracy and compliance. As of January 2026, SHN is continuing to refine and update its procurement procedures to ensure full compliance with Uniform Guidance and alignment across all federal grant–related purchasing activities. This will be completed by June 30, 2026. Proposed completion date: Management will develop procedures for Board of Directors approval in June 2026.
Corrective Action: SHN will develop a comprehensive Federal Grants Management Policy Manual, including procurement-related procedures that fully align with the requirements of Uniform Guidance (2 CFR 200.320). The draft manual and related procedures will be reviewed by an external Federal Grants Man...
Corrective Action: SHN will develop a comprehensive Federal Grants Management Policy Manual, including procurement-related procedures that fully align with the requirements of Uniform Guidance (2 CFR 200.320). The draft manual and related procedures will be reviewed by an external Federal Grants Management Specialist to ensure accuracy and compliance. As of January 2026, SHN is continuing to refine and update its procurement procedures to ensure full compliance with Uniform Guidance and alignment across all federal grant–related purchasing activities. This will be completed by June 30, 2026. Proposed completion date: Management will develop procedures for Board of Directors approval in June 2026.
Management’s Corrective Action Plan: 1. Strengthen Interdepartmental Coordination Aiken Technical College will enhance collaboration between Academic Affairs, the Registrar, and Financial Aid to ensure timely and accurate reporting of Last Dates of Attendance (LDA). This includes: Establishing a sta...
Management’s Corrective Action Plan: 1. Strengthen Interdepartmental Coordination Aiken Technical College will enhance collaboration between Academic Affairs, the Registrar, and Financial Aid to ensure timely and accurate reporting of Last Dates of Attendance (LDA). This includes: Establishing a standardized communication protocol for timely submission of LDAs following student withdrawals. Ensuring withdrawal data is entered into the student information system promptly to trigger R2T4 processing. 2. Faculty Communication and Compliance To reduce delays and improve reporting accuracy: Faculty will receive term-based reminders regarding the importance of accurate and timely drop/withdrawal reporting. Reminders will reinforce federal compliance expectations and highlight the downstream impact on student financial responsibility and institutional audit outcomes. 3. Policy and Procedure Revision The College will revise its policies and procedures to: Clearly define internal timelines, responsibilities, and handoff points across departments. Increase transparency of each step in the workflow to improve consistency and reduce processing errors. Support a collaborative, student-centered process that aligns with Aiken Technical College’s commitment to regulatory excellence and audit readiness. Responsible Official: Melinda Rodgers, VP Enrollment Mgmt. & Student Affairs Anticipated Implementation Date: Fiscal Year 2026
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063 Recommendation: We recommend that the College review its procedures to ensure their internal system pulls the correct SAI amounts directly from the student's ISIR when calculating a student’s Pell award. Explanation of disa...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063 Recommendation: We recommend that the College review its procedures to ensure their internal system pulls the correct SAI amounts directly from the student's ISIR when calculating a student’s Pell award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure compliance, the College will implement the following corrective actions: 1. System Configuration Review: The Financial Aid Office, in coordination with Powerfaids (College Board), will conduct a comprehensive review of system configuration settings to confirm that SAI values are pulled directly and accurately from the student’s valid ISIR transaction when calculating Pell eligibility when PARM ROLL is run each year. 2. Validation and Testing: The College will perform test file reviews comparing ISIR SAI values to system-calculated Pell awards to confirm accuracy. Any discrepancies identified will be corrected through system reconfiguration or vendor-supported adjustments (as per College Board.) 3. Quality Control Review: A secondary-level review, (i.e., the counselors designated to their individual alphabet cohort) will be implemented during each awarding cycle to confirm that Pell awards align with the student’s valid SAI and enrollment intensity. These corrective actions strengthen internal controls over Pell awarding, ensure SAI data integrity, and mitigate the risk of future calculation discrepancies. Name(s) of the contact person(s) responsible for corrective action: Stephanie Schroeder, Director of Financial Aid Planned completion date for corrective action plan: Immediate action will take place, with the goal of implementing these changes effectively before the start of the new academic year
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are r...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are returned within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In the absence of the Bursar due to short-term disability, the Associate Bursar was not fully trained in processing credit balances within the required timeframe. Since then, under direction of the Bursar, the Associate Bursar has been trained and occasionally processes credit balances to ensure comfortability and accuracy. The College has evaluated and updated its policies and procedures regarding student credit balances to ensure that any credit balances as a result of Title IV aid are returned within the required timeframe. Name(s) of the contact person(s) responsible for corrective action: Julie Lanski, Director Student Financial Services/Bursar Planned completion date for corrective action plan: May 31, 2026
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend that the College review its reporting procedures to COD to ensure disbursements are reported timely and accurately to be in compliance with regulations. Explanati...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend that the College review its reporting procedures to COD to ensure disbursements are reported timely and accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure compliance, the College will implement the following corrective actions: 1. Established Reporting Timeline: All disbursements will be reported to COD within fifteen calendar days of the date of disbursement, in accordance with federal regulations. 2. Secondary-Level Review: We will make it a goal to have another person within the student finance office trained to perform bi-weekly or monthly reviews of COD transmission reports to confirm accuracy and completeness. Evidence of review will be documented and retained. These corrective actions strengthen internal controls, enhance monitoring processes, and ensure disbursements are reported to COD timely and accurately moving forward. Name(s) of the contact person(s) responsible for corrective action: Stephanie Schroeder, Director of Financial Aid Planned completion date for corrective action plan: Immediate action will take place, with the goal of implementing these changes effectively before the start of the new academic year
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College review its reporting procedures to ensure that key line Items within the Fiscal Operations Report and Application to Participate (FISAP) are reviewed ...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: We recommend the College review its reporting procedures to ensure that key line Items within the Fiscal Operations Report and Application to Participate (FISAP) are reviewed and accurately reported to Department of Education as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Controller will ensure that when reporting revenue on the FISAP that it properly breaks out Graduate tuition separately from all other Tuition. Name(s) of the contact person(s) responsible for corrective action: Lisa Ressman, Controller Planned completion date for corrective action plan: February 17, 2026
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reporting student's verification statuses to COD timely and accurately to be in compliance with regulations. Explanati...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reporting student's verification statuses to COD timely and accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure compliance, the College will implement the following corrective actions: 1. Policy Update: The Financial Aid Policies and Procedures will be revised to formally document procedures for reporting verification status updates to COD, including defined timelines and assigned responsibilities within the office. 2. Established Reporting Timeline: Verification status updates will be submitted to COD within ten business days of verification completion or any change impacting Pell eligibility. 3. Tracking and Oversight: A verification tracking log will be implemented to document completion dates and COD reporting dates within the Powerfaids system to ensure verification tasks are completed. 4. Staff Training: Financial aid staff will receive training in updated procedures and COD reporting requirements. These measures strengthen internal controls, enhance oversight, and ensure timely and accurate reporting of verification statuses to COD moving forward. Name(s) of the contact person(s) responsible for corrective action: Stephanie Schroeder, Director of Financial Aid Planned completion date for corrective action plan: Immediate action will take place, with the goal of implementing these changes effectively before the start of the new academic year.
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on determining student's withdrawals, specifically the proper calculation elements and proper rounding were necessary to ...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on determining student's withdrawals, specifically the proper calculation elements and proper rounding were necessary to ensure timely and accurate returns of Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Break days of 5 consecutive days or more were incorrectly added to PowerFaids during setup. The College has reviewed and updated its policies and procedures to show that both the Director of Financial Aid and the Bursar will review the number of days to be entered into PowerFaids to ensure that prior and post-weekend days are included in the scheduled break when applicable. 2) In manually calculating the Return of Title IV Funds, the adding machine was inadvertently not set to round to three decimal places as required. The Bursar is responsible for calculating Return of Title IV funds and will ensure that any manual calculations are rounded to three decimal places as required. Policies and procedures have been updated to reflect the requirements of this critical step. Name(s) of the contact person(s) responsible for corrective action: Julie Lanski, Director Student Financial Services/Bursar Planned completion date for corrective action plan: May 31, 2026
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reviewing enrollment status changes to NSLDS to ensure that all status changes are being reported timely and accuratel...
Student Financial Assistance Cluster – Federal Assistance Listing No. 84.063, 84.268, 84.007, 84.038, 84.033 Recommendation: The College should review its policies and procedures on reviewing enrollment status changes to NSLDS to ensure that all status changes are being reported timely and accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar will review and strengthen the enrollment report to ensure it pulls all required information according to the needs of the National Student Clearinghouse (NSCL) and the NSLDS. The Registration and Records Office will continue to work with NSCL and NSLDS on specific enrollment scenarios that require different submission update requirements. Name(s) of the contact person(s) responsible for corrective action: Katelyn Letizia, Interim Vice President Institutional Effectiveness and Academic Strategy. Planned completion date for corrective action plan: May 31, 2026
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College evaluate its procedures and a policy around how Subsidized Stafford loans are calculated, awarded, and packaged. Explanation of disagreement with audit finding: There is no disagreement with...
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend the College evaluate its procedures and a policy around how Subsidized Stafford loans are calculated, awarded, and packaged. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The long-established process for prorating direct student loans for students entering their last term of study and scheduled to attend less than a full year relies on a loan proration chart kept by the financial aid office. This situation affects very few students each year. A minor error was made on one student’s award due to using an outdated proration chart. As soon as the error was discovered, the chart was updated and its accuracy will be confirmed annually.
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the College review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the College review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Additional IT resources have been employed to enable work to progress on the following WISP policies, targeting completion by May 31, 2026: - Change Management Policy - Periodic User Access Review Policy - Data Handling Policy - Patch Management Policy Name(s) of the contact person(s) responsible for corrective action: Mary Alma Noonan, Matthew Hoban Planned completion date for corrective action plan: May 31, 2026
Condition/Finding: The District failed to properly report capital assets at historical cost and/or include purchases on the capital asset report that exceed the capitalization threshold of $2,000. In addition, depreciation was not being calculated for all eligible assets. Recommendation: Procedures ...
Condition/Finding: The District failed to properly report capital assets at historical cost and/or include purchases on the capital asset report that exceed the capitalization threshold of $2,000. In addition, depreciation was not being calculated for all eligible assets. Recommendation: Procedures should be established and implemented to ensure all eligible items purchased are included in the capital asset report and depreciation is properly calculated. All eligible items should be tagged as received. Also, all items includedon the capital asset report should be reviewed to ensure the items are still in use. . Method of Implementation:Historical ledger reconstruction & system migration: The District will initiate a Request for Proposal to engage a professionalvaluation firm to perform a comprehensive reconstruction of the fixed asset ledger at historical cost. Upon completion, theresulting data file will be migrated into the district’s financial software, Edumet, to automate future depreciationcycles.
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