Corrective Action Plans

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DHS’ Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: The BOO will work with the EBT Project Office to create a dedicated section in the OIM EBT Procedure Manual to document the exceptions identified during the single audit ea...
DHS’ Office of Income Maintenance (OIM) Bureau of Operations (BOO): BOO will take the following actions to address the finding: The BOO will work with the EBT Project Office to create a dedicated section in the OIM EBT Procedure Manual to document the exceptions identified during the single audit each year. This addition will ensure that all offices are informed of the issues, can review their processes and procedures, and can make any necessary corrections. It will be added by April 1, 2026. The below items will be included: Knowing how to reconcile: • The Roles/Permissions Report from the EBT Card Tracking Database. • The Daily Log Summary and Weekly log report in the EBT Card Tracking Database. Reminders of the following concerns: • EBT card creation should end, and all cards should be logged in the EBT Card Tracking Database, by the close of business each day. No cards should be created after 5 PM. • When to use EBT Card Tracking Paper Logs, and how long to maintain them. • Ensuring that, upon receipt of each shipment of EBT cards and related supplies, the shipping manifest date is stamped. • Mailing locally created EBT cards directly to customers on the same day that the card is created. • Timeframes for completing and submitting the EPPIC EBT Systems Application forms to the OIM EBT Project Office. • Timeframe to deactivate user access in the EBT Card Tracking Database. • Timeframe for when to enter a shipment received into the EBT Card Tracking Database. The BOO, in conjunction with the EBT Project Office, distributes attestation forms to staff each year, typically during the first quarter. Employees are required to sign and return these forms to confirm that they have reviewed the procedure manual. The form for this cycle was sent out in February 2026. Anticipated Completion Date: 04/01/2026 Contact Name: Jeanette Coulston, Staff Assistant to BOO Director OIM Bureau of Program Evaluation (BPE) Division of Corrective Action (DCA): BPE will take the following actions to address the finding: The DCA conducts EBT Card Security reviews at every CAO and District Office that issues EBT cards. These reviews are conducted on a 3-year rotation to ensure compliance with documented policies and procedures. Annually, BPE/DCA EBT Headquarters staff provide training to DCA Income Maintenance Examiners in both field offices, to ensure awareness of any policy or procedure changes, prior to the start of EBT reviews. This training occurred on October 2, 2025. The current rotation schedule spans FFY 2025 through FFY 2027. Anticipated Completion Date: 04/01/2026 Contact Names: Amira Milikin, DCA Director; Bryan Bumpers, EBT Project Officer
PDA: PDA is creating mechanisms to fulfill the requirements for pass-through entities within 4 to 6 months after FAC acceptance date of the audit, which include: 1. Evaluation of single audit report submissions received from BAFM to determine program purpose acceptability by verifying, at a minimum,...
PDA: PDA is creating mechanisms to fulfill the requirements for pass-through entities within 4 to 6 months after FAC acceptance date of the audit, which include: 1. Evaluation of single audit report submissions received from BAFM to determine program purpose acceptability by verifying, at a minimum, that all agency-funded programs are properly included on the applicable financial schedules; that findings affecting the agency contain sufficient information to facilitate a management decision; and that the subrecipient has submitted an adequate corrective action plan. 2. Issuance of management decisions relative to audit findings and crosscutting findings assigned to the agency for resolution, as required by 2 CFR §200.521. 3. To impose or coordinate the imposition of remedial action in accordance with 2 CFR Part 200.339 and Management Directive 325.08 Amended, Remedies for Recipient Noncompliance with Audit Requirements, when subrecipients fail to comply with the provisions of Subpart F. PDA has developed a SEFA reconciliation process that will ensure that the SEFA is accurate, allowing for major programs to be properly identified and subjected to audit. PDA is developing a procedure for all programs to follow for any entity that is in non-compliance with the audit requirements and is failing to comply with the provisions of Subpart F. Anticipated Completion Date: 06/30/2026 Contact Name: Nichole Nedinsky, Fiscal Management Specialist, PDA Audit Coordinator PDOA: 1. Strengthen written policies and procedures governing subrecipient monitoring and audit resolution. 2. Update the audit tracker to proactively ensure the six-month management decision due date is met. 3. Implement segregation of duties between reconciliation review and management decision issuance. 4. PDOA will develop and utilize a standardized SEFA Review Checklist. 5. Conduct annual Uniform Guidance training for fiscal staff. Anticipated Completion Date: 06/30/2026 Contact Names: Jason Kavulich, Secretary of Aging; Jennifer Beck, Fiscal Management Specialist & PDOA Audit Liaison PDE: Implemented 2/17/26: Audit Coordinator verifies finding status of all single audit packages uploaded to the PDE single audit SharePoint site. Implemented 7/1/25: PDE audit section has begun to enforce timely audit submission by using remedial action within its authority as granted by federal guidelines. Implemented 7/1/25: PDE has expanded the resources available through the use of the compliance office for audit finding review and resolution in an effort to resolve all audit findings timely. Anticipated Completion Date: Completed Contact Name: Clayton P. Carroll, II, Audit Coordinator PENNVEST: PENNVEST will maintain a comprehensive tracking list that contains all equivalency projects that have disbursed any funds during the audit period. All those projects will be reviewed and reconciled to ensure that the subrecipient complies with Federal statutes, regulations, and the terms and conditions of the subaward, including the timely submission of the single audit to the FAC. Once received, PENNVEST will reconcile the SEFA to ensure the information is accurate. PENNVEST will complete the reconciliation within six months of the FAC’s acceptance of the audit report and respond to the subrecipient with any adverse findings. Anticipated Completion Date: Completed Contact Names: Steven Anspach, Dep. Exec. Dir.; Heather Brookmyer, Loan Service Officer; Robert Boos, Exec. Dir.
PDA: The Pennsylvania Department of Agriculture (PDA) Bureau of Food Assistance has already put the following steps in place to address this deficiency and noncompliance finding. 1. As of August 2025, PDA has a documented process to evaluate each subrecipient’s risk of noncompliance with federal sta...
PDA: The Pennsylvania Department of Agriculture (PDA) Bureau of Food Assistance has already put the following steps in place to address this deficiency and noncompliance finding. 1. As of August 2025, PDA has a documented process to evaluate each subrecipient’s risk of noncompliance with federal statutes, regulations, and the term and conditions of the subaward for purposes of determining appropriate subrecipient monitoring. The evaluation process looks at Key Performance Indicators – such as leadership tenure, prior incidents of food spoilage, complaints, values of USDA Foods and USDA administrative funding – to determine the need for additional or more frequent monitoring. 2. As of October 2025, PDA has implemented a system to document the evaluation of each subrecipient’s risk of noncompliance. This system was used to determine if agencies would receive monitoring reviews throughout Federal Fiscal Year 2026 (October 1, 2025 - September 30, 2026). 3. PDA has been providing FAINs and providing information on applicable requirements at the time of subawards to all TEFAP counties and agencies. However, as the cited CSFP contract pre-dated this finding, the information had not been properly provided to our subrecipient. This has been rectified as of February 2026. Anticipated Completion Date: Completed Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance PDOA: 1. Revise the risk-based subrecipient monitoring procedures. 2. Establish a formal risk-tiered monitoring framework requiring enhanced oversight for high-risk subrecipients. 3. Update written policies and procedures to meet standards. 4. Conduct annual internal compliance review of a sample of subawards. Anticipated Completion Date: 06/30/2026 Contact Names: Jason Kavulich, Secretary of Aging; Jennifer Beck, Fiscal Management Specialist & PDOA Audit Liaison
PDOA: 1. Strengthen internal controls over program income. 2. Recalculate FFY 2024 program income balances and submit amended report. 3. Implement a tracking log to actively monitor program income reporting levels. 4. Improve reporting of cost sharing and program income to ensure it is in compliance...
PDOA: 1. Strengthen internal controls over program income. 2. Recalculate FFY 2024 program income balances and submit amended report. 3. Implement a tracking log to actively monitor program income reporting levels. 4. Improve reporting of cost sharing and program income to ensure it is in compliance with federal regulations. 5. Provide training to PDA and AAA fiscal staff on program income. Anticipated Completion Date: 06/30/2026 Contact Names: Jason Kavulich, Secretary of Aging ; Jennifer Beck, Fiscal Management Specialist & PDOA Audit Liaison OB-OCO: As of 02/25/2026, the procedures for preparing the Federal Financial Report (SF‑425) were updated to include additional controls for reviewing and certifying the report prior to submission. These updates require the Pennsylvania Department of Aging to verify all program income forms to ensure they are relevant and applicable to the reporting period covered by the SF‑425. The updated procedures also require PDOA to conduct a full review of the SF‑425 and certify its accuracy via email before the Bureau of Accounting and Financial Management completes the submission in PMS. By June 30, 2026, OCO will further enhance the accuracy of financial reporting on the SF‑425 by updating the Title III working papers to incorporate linked data sources and formulas, reducing reliance on manually entered figures. Anticipated Completion Date: 06/30/2026 Contact Names: Jamie Jerosky, BAFM Assist. Director; Matt Stubb, BAFM Integrated Financial Service Mgr.; Carol Waite, BAFM Mgr.
1. Recalculate the three-year MOE average and FFY 2024 qualifying state expenditures and reconcile to the Commonwealth’s accounting records. 2. Submit a corrected MOE Certification to HHS/ACL and formally notify the federal awarding agency of the error. 3. Revisit the existing MOE procedure that def...
1. Recalculate the three-year MOE average and FFY 2024 qualifying state expenditures and reconcile to the Commonwealth’s accounting records. 2. Submit a corrected MOE Certification to HHS/ACL and formally notify the federal awarding agency of the error. 3. Revisit the existing MOE procedure that defines qualifying expenditures, calculation methodology, documentation standards, and retention requirements. 4. Review current multi-level review process. 5. Implement quarterly MOE monitoring and variance analysis comparing projected state expenditures to required MOE levels, with reporting to leadership. 6. Provide mandatory training to fiscal staff on MOE requirements and 45 CFR §1321.9(c)(2)(vi). Anticipated Completion Date: 06/30/2026 Contact Names: Jason Kavulich, Secretary of Aging ; Jennifer Beck, Fiscal Management Specialist & PDOA Audit Liaison
1. Revise the written, risk-based subrecipient monitoring procedures in accordance with 2 CFR §200.332. 2. Conduct an annual risk assessment of all 52 AAAs and assign risk ratings. 3. Implement an annual monitoring schedule ensuring coverage of active grant years (FY2024 and forward). 4. Complete ca...
1. Revise the written, risk-based subrecipient monitoring procedures in accordance with 2 CFR §200.332. 2. Conduct an annual risk assessment of all 52 AAAs and assign risk ratings. 3. Implement an annual monitoring schedule ensuring coverage of active grant years (FY2024 and forward). 4. Complete catch-up monitoring of all subrecipients not reviewed for FY2024 and FY2025 within 12 months. 5. Revise monitoring checklists to require review of current-year expenditures to verify compliance. 6. Improve centralized tracking system for monitoring activities and audit reviews. 7. Confirm supervisory approval following completion of monitoring reports. 8. Provide mandatory staff training on 45 CFR §1321.9 and 2 CFR Part 200 requirements. 9. Develop quarterly compliance reporting to leadership to ensure ongoing oversight. Anticipated Completion Date: 06/30/2026 Contact Names: Jason Kavulich, Secretary of Aging ; Jennifer Beck, Fiscal Management Specialist & PDOA Audit Liaison
The MatrixCare SOC2 report for 2025 was received on Friday February 6, 2026 and was reviewed by the Agency’s Information Technology (IT) Executive. The Agency’s Information Technology Executive/designee will educate the Information Technology Project Manager to request from Matrixcare on an annual b...
The MatrixCare SOC2 report for 2025 was received on Friday February 6, 2026 and was reviewed by the Agency’s Information Technology (IT) Executive. The Agency’s Information Technology Executive/designee will educate the Information Technology Project Manager to request from Matrixcare on an annual basis the SOC2 report and will review compliance criteria such as data security and confidentiality. An Agency Information Technology Resource Account will be developed for the SOC2 report/s to be sent to for review. Future contracts will request the vendor to automatically send SOC2 reports to the established IT Resource Account. Matrixcare security templates for Healthcare Record access have been updated by the Change Management Committee and activated by the Nurse Administrator-Technical for all users to ensure appropriate access. The Agency’s Human Resources Field Operations Manager/designee will educate the State Veterans Home (SVH) Human Resources Assistants of their responsibilities for on-boarding and off-boarding documentation for employee hires, classification changes and separations and of the DMVA’s Onboarding and Offboarding User Guides. The SVH Human Resource Analyst/designee will provide to the SVH Privacy Officer/designee all employee actions monthly to review for appropriate Healthcare Record access, the Bureau of Veterans Homes (BVH) Healthcare Record Management protocol will be updated to reflect this audit. The Agency’s Privacy Officer/designee will review 25% of all employee actions annually during each State Veterans’ Homes’ Facility Performance Assessment (FPA) to verify appropriate Healthcare Record access, the BVH FPA Protocol will be updated to reflect this audit. Anticipated Completion Date: 04/15/2026 Contact Name: Barbara L. Raymond, Director, Bureau of Veterans Homes
Alfred Yaney, Director, Enterprise e-Grants, opened a remedy ticket requesting to have the e-Grants group removed from the list of permitted groups. Screenshots were provided to the auditors as evidence of all the groups that have Admin access to validate the requested group had been removed. Antici...
Alfred Yaney, Director, Enterprise e-Grants, opened a remedy ticket requesting to have the e-Grants group removed from the list of permitted groups. Screenshots were provided to the auditors as evidence of all the groups that have Admin access to validate the requested group had been removed. Anticipated Completion Date: Completed Contact Name: Carolyn McCarthy, Head of Governance, Risk and Compliance
The Pennsylvania Department of Agriculture, Bureau of Food Assistance is in the process of developing a procedure to ensure that a report of review findings is submitted to each eligible agency after their review. This procedure will also ensure that, if the review resulted in findings that require ...
The Pennsylvania Department of Agriculture, Bureau of Food Assistance is in the process of developing a procedure to ensure that a report of review findings is submitted to each eligible agency after their review. This procedure will also ensure that, if the review resulted in findings that require implementation of corrective actions, additional monitoring is conducted until the eligible agency has successfully taken actions to mitigate the deficiencies. Anticipated Completion Date: 09/30/2026 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance
Finding 1181238 (2025-001)
Material Weakness 2025
Finding 2025-001 N. Special Tests and Provisions – N6. NSLDS Reporting Identification of the federal program: Federal Grantor: United States Department of Education Federal Cluster: Student Financial Assistance (SFA) Cluster Assistance Listing Nos.: 84.063, Federal Pell Grant Program, and 84.268, Fe...
Finding 2025-001 N. Special Tests and Provisions – N6. NSLDS Reporting Identification of the federal program: Federal Grantor: United States Department of Education Federal Cluster: Student Financial Assistance (SFA) Cluster Assistance Listing Nos.: 84.063, Federal Pell Grant Program, and 84.268, Federal Direct Student Loans Award Period of Performance: July 1, 2024–June 30, 2025 Condition: Internal controls over the review and approval of the enrollment report sent to the third-party servicer, National Student Clearinghouse (NSC), were not adequately designed or operating effectively as follows: • A record count reconciliation between the enrollment report submitted to the NSC and the number of files received by the NSC, and documentation over how any rejected records were addressed, is not performed as part of the internal control. • Details of the validation of student information included in the enrollment report for accuracy prior to being sent to the NSC were not retained by Mercy Health. • Details of the NSC error report and corrections made were not retained by Mercy Health. Views of Responsible Officials and Planned Corrective Actions: 1. Corrective Action: Record Count Reconciliation & Rejected Records • Implement a mandatory, documented reconciliation process for every submission. 2. Corrective Action: Pre-Submission Validation Documentation • Formalize the validation process and retain evidence of accuracy checks. 3. Corrective Action: Retention of NSC Error Reports & Corrections • Establish a procedure for downloading and retaining error reports. By implementing these actions, Southeast Missouri Hospital College of Nursing & Health Sciences will ensure compliance with federal regulations regarding the accuracy and timeliness of student enrollment reporting to the NSC and NSLDS. Responsible Party: Steve Ritter, Registrar and/or Deanna Sells, Business Officer Date of Completion: Phased implementation began in January 2026 and our action plan will be fully implemented as of the March 2026 enrollment reporting process.
Finding 2025-001: Timely Remittance of Earned Interest Federal Programs ALN: 93.575, 93.596, 93.558, and 93.667 Responsible Party: Alison Fraga, Chief Executive Officer Anticipated Completion Date: Management response: Concur. Corrective Action Plan: Coalition management will make sure that measures...
Finding 2025-001: Timely Remittance of Earned Interest Federal Programs ALN: 93.575, 93.596, 93.558, and 93.667 Responsible Party: Alison Fraga, Chief Executive Officer Anticipated Completion Date: Management response: Concur. Corrective Action Plan: Coalition management will make sure that measures are in place to ensure all DEL funding is always held in interest bearing bank accounts and returned timely in accordance with rules and regulations
FINDING 2025-005 SPED Procurement and Suspension and Debarment Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of...
FINDING 2025-005 SPED Procurement and Suspension and Debarment Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Accounting Department will start keeping a binder that will include all the Procurement and Suspension and Debarment Certificates pertaining to the vendors in our federal programs that equal or exceed $25,000 for each school year. The A/P Clerk will alert the Treasurer when a certificate is needed, and the Treasurer will first check SAM, and then proceed with collecting a certificate from the vendor if one is not found online. When applicable, we can add a clause or condition to a contract noting this acknowledgement. Anticipated Completion Date: This process will be in place by the end of the current fiscal year, June 30, 2026.
FINDING 2025-004 CNC Procurement and Suspension and Debarment Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsib...
FINDING 2025-004 CNC Procurement and Suspension and Debarment Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Accounting Department will start keeping a binder that will include all the Procurement and Suspension and Debarment Certificates pertaining to the vendors in our federal programs, which includes Child Nutrition, that equal or exceed $25,000 for each school year. The A/P Clerk will alert the Treasurer when a certificate is needed, and the Treasurer will first check SAM, and then proceed with collecting a certificate from the vendor if one is not found online. When applicable, we can add a clause or condition to a contract noting this acknowledgement. Anticipated Completion Date: This process will be in place by the end of the current fiscal year, June 30, 2026.
FINDING 2025-003 CNC Eligibility Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Co...
FINDING 2025-003 CNC Eligibility Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Patty Kelley Contact Phone Number and Email Address: 812-913-9622 pkelley@bhsc.school Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Direct Certification downloads will be done once a month by the Cafeteria Director. The Cafeteria Director will sign the report and forward it to the Treasurer for verification and a second signature. The Direct Certification reports will be kept at the central office. Anticipated Completion Date: This process will be in place by the end of the current fiscal year, June 30, 2026.
RAYNE HOUSING AUTHORITY 1011 The Boulevard Rayne, LA 70578 Phone No. (337) 334-3084 Fax No. (337) 334-0838 HOUSING AUTHORITY OF RAYNE, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2025 2025-001-CFP funds not timely advanced and spent-Cash Management Condition (a)-for the 2019 CFP, HUD r...
RAYNE HOUSING AUTHORITY 1011 The Boulevard Rayne, LA 70578 Phone No. (337) 334-3084 Fax No. (337) 334-0838 HOUSING AUTHORITY OF RAYNE, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2025 2025-001-CFP funds not timely advanced and spent-Cash Management Condition (a)-for the 2019 CFP, HUD recaptured $37,037, due to the obligation date being missed. (b)-for the 2021 CFP, $15,909 was recaptured, due to the obligation date being missed. (c)-for the 2020, 2022, and 2023 CFPs, HUD has suspended the drawdowns. (d)-for the 2024 and 2025 CFP grants, as of September 30, 2025, zero had been expended or advanced. HUD has also suspended drawdowns for these grants. Corrective Action Planned: I am Jill Rochon, Executive Director and Designated Person to answer this finding. I will follow the auditor’s advice. I have been in phone contact with HUD-New Orleans about this situation. Person Responsible for Corrective Action: Jill Rochon, Executive Director Telephone: (337) 334-3084 Housing Authority of Rayne Fax: (337) 334-0838 1011 The Boulevard Rayne, LA 70578 Anticipated Completion Date- September 30, 2026
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are follow...
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are following these procedures consistently.
REFERENCE: 2025-101 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2025 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 256AZ003N1199 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of t...
REFERENCE: 2025-101 CFDA NUMBER: 10.558 – CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2025 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 256AZ003N1199 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Claudia Cordova, Director 2. Corrective action planned: AAFDCP will continue to follow the menu reading policy of reading 100% of all menus/OERS before submitting the Claim to The ADE and of double checking each person’s work by exchanging menus/OERs to include checking for clerical errors and creditable food components. The person reviewing the menus/OERs will initial the form to indicate it has been reviewed. All visit forms will be checked by The Director, Claudia Cordova, Assistant Director Cathy Reagan and Bi-lingual Specialist Veronica Mendoza before entering the data into KidKare to ensure all information is complete and accurate. The initials of the person double checking the form will be added to the bottom of the visit form along with the date it was reviewed. 3. Anticipated completion date: Ongoing process already implemented
Views of Responsible Officials: The College acknowledges the audit finding that Return of Title IV (R2T4) calculations were not accurately completed for nine of the sixty students sampled, and that Title IV funds were not returned timely for fifteen of the sixty students sampled. During the audit pe...
Views of Responsible Officials: The College acknowledges the audit finding that Return of Title IV (R2T4) calculations were not accurately completed for nine of the sixty students sampled, and that Title IV funds were not returned timely for fifteen of the sixty students sampled. During the audit period, R2T4 tracking and oversight processes were in transition, which resulted in insufficient monitoring of calculation accuracy and timeliness. In addition, for several end-of-term cases involving unofficial withdrawals, the institution could not initiate R2T4 calculation until final grades were posted and an unofficial withdrawal determination was made based on non-passing (F) grades, in accordance with federal regulations governing unofficial withdrawals. The Fall 2024 semester ended on December 21st. The college was closed for the winter break and reopened January 2, 2025. Therefore, the Date of Determination (DOD) was not two days after the end of the semester but in January with the earliest available processing date being January 2, 2025. Corrective Action: The College has implemented enhanced internal controls to ensure compliance with Return of Title IV (R2T4) requirements. Responsibility for monitoring R2T4 calculations and timeliness has been assigned to the Director of Financial Aid and Compliance. A R2T4 tracking log has been established and is reviewed on a weekly basis to ensure that all official withdrawals are identified and processed within the required regulatory timeframe. For unofficial withdrawals, R2T4 calculations are initiated after the end of term once final grades are posted and an unofficial withdrawal date of determination (DOD) is made based on non-passing (F) grades, consistent with federal regulations. End-of-term R2T4 reviews for the fall semester are conducted upon return from winter break after the New Year to ensure complete and accurate academic records are available. Internal staff have received additional training on R2T4 regulatory requirements, timelines, and documentation standards. To ensure operational continuity, a senior specialist has been trained to manage R2T4 processing in the Director's absence. These corrective actions will strengthen internal controls and ensure accurate and timely processing of R2T4 calculations.
Views of Responsible Officials: After consultation with the College’s Information Technology department, management determined that the file was processed and submitted on time. However, the NSLDS discrepancy resulted from a data processing issue during the March 2025 enrollment status download. Spe...
Views of Responsible Officials: After consultation with the College’s Information Technology department, management determined that the file was processed and submitted on time. However, the NSLDS discrepancy resulted from a data processing issue during the March 2025 enrollment status download. Specifically, while the NSLDS file was being generated, staff from another office were simultaneously accessing the same student records. These concurrent activities caused the affected students’ enrollment statuses to default to data from a prior download, resulting in incorrect reporting for the two records of the sixty examined. Corrective action: The College has revised its NSLDS data reporting process to prevent a recurrence of concurrent access. A static, saved population list is now used to generate NSLDS enrollment status downloads, eliminating conflicts caused by concurrent system access. This change ensures that enrollment status data is not impacted and remains consistent at the time of submission. Management believes this corrective action adequately addresses the identified issue, strengthens controls, mitigate this issue for future status change reports, and allows for accurate submission within the required 60-day timeframe.
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS ...
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS Financial modules. IAM team will establish a documented process through which it will coordinate with the CAPPS Financial team to perform quarterly reviews of accounts and audit logs to strengthen privileged access provisioning. The review process will include documented approval, business justification, and periodic revalidation for all elevated roles in CAPPS Financial. Pathlock software is being used to manage single sign-on for granting privileged access to allowed users. With this software, the IAM team can grant access to a user, who would then login as themselves and then switch to the appropriate privileged role. Once the user switches to a privileged role, the Pathlock software maintains the audit log of user activity. Implementation date: February 27, 2026 Responsible persons: Daniel Kellogg, Deputy Chier Information Officer (DCIO), Infrastructure Services Leatha Marr, DCIO & Chief Product Officer, System Applications
Corrective action plan: Long Term Care Regulation will enhance existing internal controls to ensure timely completion and distribution of Form 2567 to the providers. Implementation date: March 31, 2026 Responsible person: Michelle Dionne-Vahalik, Associate Commissioner, Long Term Care Regulations
Corrective action plan: Long Term Care Regulation will enhance existing internal controls to ensure timely completion and distribution of Form 2567 to the providers. Implementation date: March 31, 2026 Responsible person: Michelle Dionne-Vahalik, Associate Commissioner, Long Term Care Regulations
Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to...
Corrective action plan: HHS Information Security: • Has implemented a centralized governance process to ensure completion of all required biennial risk assessments. • Will establish and maintain oversight, validation, and escalation procedures for overdue assessments to ensure sustained adherence to federal and state requirements. • Will establish an inventory of systems to ensure information owners and custodians are assigned. • Will create an automated compliance dashboard to facilitate monthly reporting to executive leadership. • Will prioritize high-risk Medicaid systems, targeting completion within three months and achieving full compliance with Texas Administrative Code (TAC) 202 requirements within twelve months. The Deputy Chief Information Officers (DCIO) and Chief Product Officers for System Applications, Public Health Applications, and Texas Integrated Eligibility Redesign System (TIERS)/Medicaid Enterprise Systems (MES) will provide support and assistance to the program areas in creating Plan of Actions and Milestones and completing risk assessments for all systems provided in the executive report for their respective areas related to the audit. Implementation date: February 28, 2027 Responsible persons: Anil Koindala, Chief Information Security Officer Leatha Marr, DCIO and Chief Product Officer, System Applications Madhavi Koganti, DCIO and Chief Product Officer, Public Health Applications James Huang, DCIO and Chief Product Officer, TIERS/MES
Corrective action plan: FDCM/OI has developed a comprehensive action plan to modernize and increase our detection of fraud in the child care program. Part of this modernization will include increased and more “real-time” monitoring of Board collection efforts. FDCM/OI is partnering with our Informat...
Corrective action plan: FDCM/OI has developed a comprehensive action plan to modernize and increase our detection of fraud in the child care program. Part of this modernization will include increased and more “real-time” monitoring of Board collection efforts. FDCM/OI is partnering with our Information, Innovation, and Insight Division (I3) to develop new dashboards and reports based upon weekly uploaded PIRTS data. This will allow FDCM/OI to generate weekly reports of Board collection letter non-compliance. If a Board fails to issue collection letters in a timely fashion, FDCM/OI will send a report to the Board Executive Director notifying them of non-compliance. Boards are also now required to have a Fraud Point of Contact (POC) that will be FDCM/OI’s direct liaison with the Board for all fraud matters. Additionally, FDCM/OI is conducting weekly PIRTS trainings throughout February for Boards. Boards have been asked to submit up to 5 fact finders who will be responsible for fraud case entry and management. The Board POC is ultimately responsible for every case. FDCM/OI is also reviewing our collection letters as a part of this process and generating prosecution referrals for cases which meet our criteria. It is our belief this will underscore the seriousness of the collection letters and increase their effectiveness. Finally, FDCM/OI will ensure that all relevant controlling documents, e.g. a new Workforce Development Letter, and all previous guidance is updated with this information. Implementation date: February 27, 2026 Responsible person: Jason Stalinsky, Division Director, Division of Fraud Deterrence and Compliance Monitoring.
Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC continues to be engaged in long-term planning related to improving FFATA reporting. Implementation date: September 1, 2027 Responsible person: Ari...
Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC continues to be engaged in long-term planning related to improving FFATA reporting. Implementation date: September 1, 2027 Responsible person: Ariana Torres, Deputy Director, Federal Funds
Corrective action plan: The Office of Area Agencies on Aging (OAAA) will update the General Revenue allocation procedures and workbook to allocate general revenue to Area Agencies on Aging (AAAs) in proportion to the associated federal awards to ensure they are not supplanting non-federal funds rela...
Corrective action plan: The Office of Area Agencies on Aging (OAAA) will update the General Revenue allocation procedures and workbook to allocate general revenue to Area Agencies on Aging (AAAs) in proportion to the associated federal awards to ensure they are not supplanting non-federal funds related to supportive services and senior centers. OAAA will provide in-service training for the OAAA Budget Analyst and Financial Analysts on the revised procedures and workbook. OAAA will provide training for AAAs on the revised procedures and workbook for managing Older Americans Act funds, General Revenue, and associated regulations. Implementation date: September 30, 2026 Responsible person: Lori Conner, Manager, OAAA Fiscal and Contract Oversight
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