Corrective Action Plans

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To enhance compliance and oversight, the Northeastern State University Grant Office has implemented a mandatory dualphase training protocol for all Principal Investigators (PIs). Starting Fiscal Year 2026, all PIs are required to complete an inital compliance training upon award initiation. Furtherm...
To enhance compliance and oversight, the Northeastern State University Grant Office has implemented a mandatory dualphase training protocol for all Principal Investigators (PIs). Starting Fiscal Year 2026, all PIs are required to complete an inital compliance training upon award initiation. Furthermore, to address findings regarding reporting timelines, the university will conduct annual refresher training for all PIs with active awards. This annual session will specifically emphasize regulatory requirements for the timely submission of technical and financial reports.
Personnel turnover within the Office of the Registrar (July 2023) and the AVP for Academic Affairs (June 2024) led to procedural gaps during these transitions. Some of the proccesses and procedures suffered from a lack of transitional clarity. The Office of the Registrar is responsible for updating ...
Personnel turnover within the Office of the Registrar (July 2023) and the AVP for Academic Affairs (June 2024) led to procedural gaps during these transitions. Some of the proccesses and procedures suffered from a lack of transitional clarity. The Office of the Registrar is responsible for updating the STVMAJR screen in Banner which is a manual process. To rectify this, we have created a streamlined process for updates to the curriculum workflow to ensure precise alignment between Banner and CIP codes. This includes a new monthly meeting between the Registrar, Associate Registrar and AVP to review all curriculum updates, modifications, and new programs to prevent future errors. Issues with the Fall 2024 degree file delayed First of Term processing for Spring 2025. A defect introducted by an Ellucian update affected the degree file output and was resolved by updating the Banner page STVACAT (specifically the NSC Credential Level Translation column). This issue is not expected to recur. Spring 2025 First of Term processing was also delayed due to the manual creation of approximately 200 Social Security Numbers for newly admitted international students following the SLATE implementation and Admissions staffing turnover. This process has since been automated through an update to an Argos generator, eliminating the need for manual SSN creation. In addition, the National Student Clearinghouse transmission schedules were updated to allow additional processing time between files and to avoid submissions during the winter break. Specifically, transmissions for Fall Subsequent of Term were moved from January 1 to January 11, Fall Graduates Only (WS) from January 4 to January 18, and the Fall Degree file from January 14 to January 25.
Corrective Action/Management Response: Ensuring that Adoption records are maintained accurately with all documented requirements. Changing Practice to include putting documents into the document management system (Traverse) in order to have a copy of required documents in the event originals are los...
Corrective Action/Management Response: Ensuring that Adoption records are maintained accurately with all documented requirements. Changing Practice to include putting documents into the document management system (Traverse) in order to have a copy of required documents in the event originals are lost, or documents are damaged due to flooding (which is what occurred in the basement where documents were housed). Cases that are more than 10 years old are typically going to be more difficult to locate needed items, due to records being maintained differently at that time and requirements were different in what the Department was required to maintain in an Adoption file. Proposed Completion Date: June 30, 2026 checking monthly to ensure paper files are scanned into Traverse.
Reference Number 2025-02 Return of Title IV Funds (R2T4) Since the 2025 audit, there have been significant improvements in oversight and process management for R2T4 calculations. A leadership transition occurred, and the Associate Director - bringing over 30 years of higher education experience, inc...
Reference Number 2025-02 Return of Title IV Funds (R2T4) Since the 2025 audit, there have been significant improvements in oversight and process management for R2T4 calculations. A leadership transition occurred, and the Associate Director - bringing over 30 years of higher education experience, including prior service as a Financial Aid Director - has assumed responsibility for R2T4 calculations for the 2026-27 academic year. To ensure compliance and accuracy, the Associate Director completed a Department of Education training refresher on R2T4 calculations during Spring 2025. Additionally, the interim Financial Aid Director implemented a structured plan to monitor all student withdrawals and guarantee timely completion of calculations. For Fall 2025, the process has remained on schedule. A two-tier accountability system is in place: the Associate Director manages calculations, and the Director provides immediate support if any delays occur. A comprehensive tracking spreadsheet was developed to record each withdrawal, including the withdrawal date, federal aid status, and the date the R2T4 calculation was completed. This tool ensures real-time monitoring and accuracy. The daily withdrawal report introduced after the 2024 audit continues to be a valuable resource; however, the combination of this report with the new tracking system and dual oversight has proven to be the cornerstone of compliance. All calculations are current, accurate, and completed within required timelines. Based on these improvements, we do not anticipate any findings in the upcoming audit.
Views of Responsible Officials and Planned Corrective Actions – The Registrar and Institutional Researcher will both ensure that any students that have updated their status are updated on a weekly basis. The Institutional Researcher will log into NSLDS to upload the file, and the CFO, Registrar, and...
Views of Responsible Officials and Planned Corrective Actions – The Registrar and Institutional Researcher will both ensure that any students that have updated their status are updated on a weekly basis. The Institutional Researcher will log into NSLDS to upload the file, and the CFO, Registrar, and Institutional Researcher will monitor updates monthly.
Views of Responsible Officials and Planned Corrective Actions – The CFO and the Students Account Manager will add a checklist step to verify the correct inclusion of all scheduled breaks in the R2T4 calculation, will implement a secondary review process to confirm data accuracy before finalizing R2T...
Views of Responsible Officials and Planned Corrective Actions – The CFO and the Students Account Manager will add a checklist step to verify the correct inclusion of all scheduled breaks in the R2T4 calculation, will implement a secondary review process to confirm data accuracy before finalizing R2T4, and will provide training to relevant staff.
Views of Responsible Officials and Planned Corrective Actions – The CFO and Student Accounts Manager has begun the process of uploading the file that specifies disbursement date in the ledger so they match one another.
Views of Responsible Officials and Planned Corrective Actions – The CFO and Student Accounts Manager has begun the process of uploading the file that specifies disbursement date in the ledger so they match one another.
Views of Responsible Officials and Planned Corrective Actions – The CFO and Student Accounts Manager will provide a listing of all students receiving a refund. A grace period of 5 days for students to provide direct deposit information will be established, if after 5 there is still no direct deposit...
Views of Responsible Officials and Planned Corrective Actions – The CFO and Student Accounts Manager will provide a listing of all students receiving a refund. A grace period of 5 days for students to provide direct deposit information will be established, if after 5 there is still no direct deposit information, a check will be issued.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure notification to federally funded employees of their funding source twice a year and will make sure supervisors get reports and sign certifications for work duties in compliance with the federal grants twice a year. Date of implementation - effective immediatel...
The Chief Financial Officer will ensure notification to federally funded employees of their funding source twice a year and will make sure supervisors get reports and sign certifications for work duties in compliance with the federal grants twice a year. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.033, 84.063 & 84.268 Recommendation: We recommend the University review credit balance refund processes, including automated processes, to ensure all credit balances are paid timely. Explanation of disagreement with audit finding...
Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.033, 84.063 & 84.268 Recommendation: We recommend the University review credit balance refund processes, including automated processes, to ensure all credit balances are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Revised the daily Title IV credit balance workflows to include credit balances of any amount. Name(s) of the contact person(s) responsible for corrective action: Valerie Marsh, Director of Student Financial Services Planned completion date for corrective action plan: December 1, 2025
Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.033, 84.063 & 84.268 Recommendation: We recommend the University review reporting processes to ensure all students that require exit counseling receive it in a timely manner. Explanation of disagreement with audit finding: There ...
Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.033, 84.063 & 84.268 Recommendation: We recommend the University review reporting processes to ensure all students that require exit counseling receive it in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The workflow FAEXIT_WDR for students who withdrew in the current term or have a late coded CWD was revised from excluding the assignment of exit counseling if exit counseling was assigned in the prior academic term to exclude only if exit counseling already exists in the current term. Name(s) of the contact person(s) responsible for corrective action: Alec Kuzmack, Business Analyst Planned completion date for corrective action plan: November 21, 2025
2025-001 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that required HQS are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
2025-001 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that required HQS are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: See narrative below. SC Housing’s inspection team strives to represent both the organization and HUD at the highest level. The HCV inspections team takes pride in being timely, professional, and thorough, as evidenced by the single finding noted in our most recent audit. SC Housing has taken several corrective steps to mitigate and prevent late inspections. First, we implemented modifications to our organizational structure. Late inspections resulted from the previous structure and business practices, which assigned staff to specific families and required them to oversee all HCV-related tasks for those families, including inspections. While this approach promoted continuity, it created challenges when staff were absent for extended periods, as there was no backup capacity to absorb the workload. As a result, SC Housing reorganized the HCV program to significantly reduce the likelihood of late HQS inspections. Inspections are now centralized as a primary function, and the inspection team has been restructured to be smaller, more flexible, and more responsive. Second, SC Housing has enhanced its monitoring processes. In addition to regularly pulling system-generated reports to identify inspections due, staff are now fully utilizing PIC reports to proactively identify families approaching the maximum 24-month inspection timeframe, thereby reducing the risk of late inspections. Lastly, staff leaves and absences are being managed more effectively to ensure adequate coverage at all times. This approach ensures that sufficient staffing is available to complete all inspection types timely and without delay. Name(s) of the contact person(s) responsible for corrective action: Lisa Wilkerson, Director of Rental Assistance and Compliance Lenzy Morris, HCV Inspections Manager Planned completion date for corrective action plan: Immediately and Ongoing If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Lisa Wilkerson at (803) 896-7030.
Congressional Directives – Assistance Listing No. 93.493 Recommendation: We recommend CAPECO ensure documentation is retained to support the date the suspension and debarment verification procedures are performed. Explanation of disagreement with audit finding: There is no disagreement with the audi...
Congressional Directives – Assistance Listing No. 93.493 Recommendation: We recommend CAPECO ensure documentation is retained to support the date the suspension and debarment verification procedures are performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CAPECO will obtain time-stamped verification support from SAM.gov to ensure that potential contractors are free from debarment and suspension prior to executing the contract. Name(s) of the contact person(s) responsible for corrective action: Paula Hall, CEO and/or Katie Smith, CFO Planned completion date for corrective action plan: Effective Immediately
FINDING 2025-002 Finding Subject: Education Stabilization Fund – Wage Rate Requirements Contact Person Responsible for Corrective Action: Tanya Pearson Contact Phone Number and Email Address: (765) 522-6218 / tpearson@nputnam.k12.in.us Views of Responsible Officials: We concur with the finding. Desc...
FINDING 2025-002 Finding Subject: Education Stabilization Fund – Wage Rate Requirements Contact Person Responsible for Corrective Action: Tanya Pearson Contact Phone Number and Email Address: (765) 522-6218 / tpearson@nputnam.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Although the Education Stabilization Fund projects have been completed, the School Corporation will implement procedures to ensure compliance with Davis Bacon and wage rate requirements for all future federally funded grants that have this stipulation. Anticipated Completion Date: Immediately (February 1, 2026)
Corrective Action Plan Related to the Schedule of Findings and Questioned Costs Student Financial Aid University of Hawaiʿi – Maui College Year Ended June 30, 2025 Finding No. 2025-002: Financial Aid Administration – Control Deficiency Federal Agency: U.S. Department of Education CFDA Number and Tit...
Corrective Action Plan Related to the Schedule of Findings and Questioned Costs Student Financial Aid University of Hawaiʿi – Maui College Year Ended June 30, 2025 Finding No. 2025-002: Financial Aid Administration – Control Deficiency Federal Agency: U.S. Department of Education CFDA Number and Title: 84.268 – Federal Direct Student Loans Questioned Costs: $-0- Responsible Individuals: Kulamanu Ishihara, Financial Aid Director, Maui College Date Action Taken: December 2, 2025 Corrective Action Plan for timely notifications for exit counseling- NSLDS reporting. 1. Financial Aid Office Staffing ● The Financial Aid Office has completed recruitment for four full-time positions, including a director to ensure adequate administrative capacity for the financial aid processes. 2. Project Prioritization ● Effective immediately, the Financial Aid Office will prioritize timely notifications and exit counseling to students with loans. 3. Project Documentation ● For any future delays due to unforeseeable circumstances, the financial aid program will provide clear, detailed justifications to ensure compliance with audit expectations. 4. Project Oversight and Monitoring ● The Vice Chancellor of Student Affairs will meet monthly with the Financial Aid Director to ensure deadlines are being met and to and monitor the progress of notifications. Expected Results Implementation of this corrective action plan will result in timely notifications of exit counseling being provided through interactive electronic notifications or by mailing counseling materials to the borrower at the borrower’s last known address within 30 days after learning that the borrower has withdrawn from the institution or failed to complete exit counseling as required.
Corrective Action Plan Related to the Schedule of Findings and Questioned Costs Student Financial Aid University of Hawaiʿi – Maui College Year Ended June 30, 2025 Finding No. 2025-001: Return of Title IV Funds – Control Deficiency Federal Agency: U.S. Department of Education CFDA Number and Title: ...
Corrective Action Plan Related to the Schedule of Findings and Questioned Costs Student Financial Aid University of Hawaiʿi – Maui College Year Ended June 30, 2025 Finding No. 2025-001: Return of Title IV Funds – Control Deficiency Federal Agency: U.S. Department of Education CFDA Number and Title: 84.063 – Federal Pell Grant Questioned Costs: $-0- Responsible Individuals: Kulamanu Ishihara, Financial Aid Director, Maui College Date Action Taken: November 25, 2025 Corrective Action Plan for timely notifications for withdrawal date determination. 1. Financial Aid Office Staffing ● The Financial Aid Office has completed recruitment for four full-time positions, including a director to ensure adequate administrative capacity for the financial aid processes. 2. Project Prioritization ● Effective immediately, the Financial Aid Office will prioritize the timely withdrawal date determination by initiating the new Kuali Build Form with routing capabilities. 3. Project Documentation ● For any future delays due to unforeseeable circumstances, the financial aid program will provide clear, detailed justifications to ensure compliance with audit expectations. 4. Project Oversight and Monitoring ● The Vice Chancellor of Student Affairs will meet monthly with the Financial Aid Director to ensure deadlines are being met and to monitor the progress of notifications. Expected Results Implementation of this corrective action plan will result in a timely determination of the withdrawal date through interactive electronic routing.
2025-002 Finding – Federal Funding Accountability and Transparency Act (FFATA)/Transparency Act Reporting (Timeliness) Federal Agency: U.S. Department of Health and Human Services (HHS) Program: Head Start Cluster – Assistance Listing 93.600 (Head Start) Compliance Requirement: Reporting (L) – FFATA...
2025-002 Finding – Federal Funding Accountability and Transparency Act (FFATA)/Transparency Act Reporting (Timeliness) Federal Agency: U.S. Department of Health and Human Services (HHS) Program: Head Start Cluster – Assistance Listing 93.600 (Head Start) Compliance Requirement: Reporting (L) – FFATA/Transparency Act Special Reporting Type of Finding: Compliance (no internal control deficiency) Finding Summary: Two first-tier subaward actions were submitted in SAM.gov after the required reporting timeframe. Based on the nature of the exceptions and the results of expanded procedures, the late submissions appear to be isolated to the period of the federal FSRS-to-SAM.gov transition rather than indicative of a systemic reporting breakdown. Management attributed the delays to federal system conversion issues, including access/role challenges, delayed training, and data migration/report rejection issues that required resolution with SAM.gov support. Accordingly, the noncompliance is limited to timeliness of transparency reporting (no questioned costs) and does not affect allowability of Head Start expenditures. Corrective Action Plan: Delays were primarily attributable to the federal transition from FSRS to SAM.gov, including access/role configuration challenges and system-related issues encountered during the conversion period. Reasonable and timely steps were taken to submit the required FFATA reports as soon as the federal system issues were resolved and to address any submission rejections or support requests as needed. Now that the filing of back logged reports is complete, we will continue with our existing FFATA reporting procedures. We will track contracts needing FFATA submission with an internal ticketing system to ensure that the filings are on time. We will retain appropriate documentation of submissions and related system communications to support compliance. We will submit said documentation to our business office as a secondary measure to ensure that the filing was done prior to processing said contract. Contact Person responsible for corrective action: Anthony Jordan, Division Director Anticipated completion date of Corrective Action Plan: This item is corrected as of 10/01/2025.
2025-001 Significant Deficiency: National Student Loan Data System (NSLDS) Report (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268 and Federal Pell Grant Program, ALN #84.063) (Repeat finding of 2022-001, 2023-003, and 2024-005) Name of Contact Person Casey Reagan, Reg...
2025-001 Significant Deficiency: National Student Loan Data System (NSLDS) Report (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268 and Federal Pell Grant Program, ALN #84.063) (Repeat finding of 2022-001, 2023-003, and 2024-005) Name of Contact Person Casey Reagan, Registrar, and Melissa White, Director of Financial Aid, are responsible for clearinghouse reporting for 2023-24. Corrective Action Planned During the audit, it was noted that the University incorrectly reported student enrollment status for changes in enrollment. The university has identified the issue that is occurring that is causing the enrollment to be reported incorrectly. We are currently working with the IT Department to fix the error that is occurring within the system itself. In the meantime, students who are impacted by the incorrect enrollment status reporting are being manually fixed in the system and then the record is being pulled and reported to clearinghouse. Overall, the university has been working to reduce the number of incorrect enrollment status reportings. This can be seen by the fact that we went from a 45% error rate in 2023-24 to a 20% error rate in 2024-25. Finally, the Registrar’s Office shall be main office reporting clearinghouse data in the future, with financial aid only acting as a secondary reporter should the Registrar’s Office not be available to report. Anticipated Completion Date 08/01/2026
Material Weakness: 2025-001 Incomplete Year-End Closing Procedures: As stated in the findings the District did not complete its year end closing process for the fiscal year. Account reconciliations were incomplete, and financial statement accounts were not properly reconciled to detailed cost report...
Material Weakness: 2025-001 Incomplete Year-End Closing Procedures: As stated in the findings the District did not complete its year end closing process for the fiscal year. Account reconciliations were incomplete, and financial statement accounts were not properly reconciled to detailed cost reports. To rectify the material weakness moving forward, the District is actively advertising for an accountant position as an addition to the Business Department. Interviews are being scheduled, and the most qualified candidate will be recommended for hire by the Board of Directors. The accountant will be performing the reconciliations of all accounts prior to the close-out at year end. A spreadsheet detailing the reconciliations for all accounts will be implemented and utilized moving forward. This will become part of the close-out process prior to beginning the audit.
If the City utilizes $750,000 or more of federal money in the future, staff will obtain training on how to complete the required yearly reporting.
If the City utilizes $750,000 or more of federal money in the future, staff will obtain training on how to complete the required yearly reporting.
When utilizing Federal grant monies, Finance will verify all vendors utilized during the fiscal year (whether or not they have been verified in the prior fiscal year), that the vendors are not suspended nor debarred from receiving such funds.
When utilizing Federal grant monies, Finance will verify all vendors utilized during the fiscal year (whether or not they have been verified in the prior fiscal year), that the vendors are not suspended nor debarred from receiving such funds.
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