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Corrective Action Plans

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Finding 1187056 (2025-001)
Material Weakness 2025
Mosaic Health System
MO
Reporting § 200.512
Management has implemented enhanced monitoring procedures, including assigning responsibility for validating the final Single Audit submission within the required deadlines, to ensure all required steps are completed timely in future periods. Mark Tighe, Director of Accounting, was responsible for t...
Management has implemented enhanced monitoring procedures, including assigning responsibility for validating the final Single Audit submission within the required deadlines, to ensure all required steps are completed timely in future periods. Mark Tighe, Director of Accounting, was responsible for the implementation of this corrective action plan. This corrective action plan has been fully implemented as of March 16, 2026.
View Audit 394744
Finding 1187048 (2025-003)
Material Weakness 2025
Jennings County School Corporation
IN
Equipment & Real Property Management § 200.313
Information on the federal program: Subject: Education Stabilization Fund (ESF) Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Federal Award Numbers and Years (Or Other Identifying Numbers): S425U210013, S4...
Information on the federal program: Subject: Education Stabilization Fund (ESF) Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Federal Award Numbers and Years (Or Other Identifying Numbers): S425U210013, S425W210015 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Equipment and Real Property Management Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirements. Context: There were nine equipment purchases made during the audit period and charged to the ESF grants which totaled $564,248 in the aggregate. During testing of equipment purchases, the following items were noted: • The School Corporation provided a capital asset listing that had not been updated since 2020. As a result, none of the equipment items selected for testing that were purchased with ESF funds were included on the listing. Additionally, the listing did not include required elements under 2 CFR §200.313(d), including documentation of the federal funding source and the condition of the property. • The School Corporation did not perform a physical inventory of equipment at least once every two years as required by 2 CFR §200.313(d)(2). As such, management was unable to demonstrate that federally funded equipment was being periodically verified and reconciled to property records. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will perform a comprehensive inventory and evaluation of all assets including those purchased with ESF funds and ensure they are appropriately recorded within a detailed asset listing. Responsible Party and Timeline for Completion: Philip Marsh / Jun 30, 2026
View Audit 394734
Finding 1187046 (2025-002)
Material Weakness 2025
Jennings County School Corporation
IN
Procurement, Suspension & Debarment § 200.303
Information on the federal program: Subject: Special Education Cluster (IDEA) – Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Cluster Assistance Listing Number: 84.027 Federal Award Numbers and Years (Or Other Identifying Numbers): H027A230084, H...
Information on the federal program: Subject: Special Education Cluster (IDEA) – Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Cluster Assistance Listing Number: 84.027 Federal Award Numbers and Years (Or Other Identifying Numbers): H027A230084, H027A240084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Suspension and Debarment Audit Findings: Significant Deficiency Condition: An effective system of internal controls was not in place at the School Corporation to ensure the School Corporation’s compliance with applicable requirements related to the Special Education Cluster (IDEA), specifically with respect to Suspension and Debarment requirements. No instances of noncompliance (entering a contract with a vendor that was suspended or debarred) were identified in the transactions selected for testing. The matter represents a deficiency in internal controls over the Suspension and Debarment process, rather than identified noncompliance with program requirements. Context: Suspension and Debarment As part of its internal control procedures, the School Corporation utilizes the System for Award Management (SAM.gov) to verify the eligibility status of vendors prior to engaging in financial transactions. This verification process is designed to ensure that vendors are not suspended, debarred, or otherwise excluded from participation in federal programs, in accordance with applicable procurement regulations. Two covered transactions that equaled or exceeded $25,000 were identified. Each of the identified transactions were selected for testing, totaling $73,208. The School Corporation did not verify the vendors' suspension and debarment status prior to payment for each of the covered transactions. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will enhance controls and review processes surrounding Procurement, Suspension and Debarment under Special Education funds to ensure all compliance requirements of the program are met. Responsible Party and Timeline for Completion: Philip Marsh / Mar 31, 2026
View Audit 394734
Finding 1187043 (2025-028)
Material Weakness 2025
State of North Carolina
NC
Period of Performance Internal Control / Segregation of Duties Subrecipient Monitoring
Grant Funds Spent After Award Ended The Division will complete the following corrective actions: •Continue cross-divisional meetings to strengthen grant oversight and fiscal monitoring. •Complete targeted training to support consistent application of requirements. •Update policies and procedures to ...
Grant Funds Spent After Award Ended The Division will complete the following corrective actions: •Continue cross-divisional meetings to strengthen grant oversight and fiscal monitoring. •Complete targeted training to support consistent application of requirements. •Update policies and procedures to reinforce verification that expenditures are incurred within the approved grant period and are supported by appropriate documentation prior to approval and payment. Anticipated Completion Date: June 30, 2026.
View Audit 394732
Finding 1187042 (2025-027)
Material Weakness 2025
State of North Carolina
NC
Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties
Overpayments to Subrecipients The Division will complete the following corrective actions: •Complete targeted training to support proper implementation of these procedures. •Update procedures to include quality assurance reviews. Anticipated Completion Date: June 30, 2026.
Overpayments to Subrecipients The Division will complete the following corrective actions: •Complete targeted training to support proper implementation of these procedures. •Update procedures to include quality assurance reviews. Anticipated Completion Date: June 30, 2026.
View Audit 394732
Finding 1187041 (2025-026)
Material Weakness 2025
State of North Carolina
NC
HIV Funds Used for Improper Payment The Department will implement the following corrective actions: •NCDHHS Office of the Controller will update their Standard Operating Procedures (SOP) for Accounts Payable (A/P) Entry when Paying Invoices Having No Reference Identifiers (SOP# AP089) to address the...
HIV Funds Used for Improper Payment The Department will implement the following corrective actions: •NCDHHS Office of the Controller will update their Standard Operating Procedures (SOP) for Accounts Payable (A/P) Entry when Paying Invoices Having No Reference Identifiers (SOP# AP089) to address the case and spacing sensitivity of the North Carolina Financial System (NCFS). •NCDHHS Office of the Controller (OOC) will conduct training to A/P staff on keying payments when an invoice does not have a reference identifier. •NCDHHS, Division of Public Health (DPH) will implement a payment reconciliation procedure within the program area to monitor payments and ensure timely identification and investigation of duplicate payments. •NCDHHS, DPH has requested a repayment from the vendor in the amount of the duplicate payment. Anticipated Completion Date: June 30, 2026.
View Audit 394732
Finding 1187040 (2025-025)
Material Weakness 2025
State of North Carolina
NC
Deficiencies in Medicaid Provider Payment Process The Department directed the Fiscal Agent to add edit 3406 (History Record Not Found for Adjustment/Void) to the timely filing bypass denial listing, preventing claims denied solely for missing history records from being used to bypass timely filing r...
Deficiencies in Medicaid Provider Payment Process The Department directed the Fiscal Agent to add edit 3406 (History Record Not Found for Adjustment/Void) to the timely filing bypass denial listing, preventing claims denied solely for missing history records from being used to bypass timely filing requirements (FMR 18318). Additionally, the Department directed the Fiscal Agent to research and identify any additional claims paid in error during the audit period because of this system gap (Service ticket 29753). The Department also initiated recoupment of the $170,041.82 overpayment from the provider. Anticipated Completion Date: June 30, 2026.
View Audit 394732
Finding 1187039 (2025-024)
Material Weakness 2025
State of North Carolina
NC
Reporting
FFATA Reporting Not Completed See 2025-023 for the Corrective Action Plan.
FFATA Reporting Not Completed See 2025-023 for the Corrective Action Plan.
View Audit 394732
Finding 1187038 (2025-023)
Material Weakness 2025
State of North Carolina
NC
Subrecipient Monitoring Reporting
FFATA Reporting Not Completed The Division of Social Services Budget Office (Division) implemented a corrective action plan focused on staff training, clearer processes, and accountability as noted below. •A training session was conducted for newly hired staff to ensure understanding of the FFATA re...
FFATA Reporting Not Completed The Division of Social Services Budget Office (Division) implemented a corrective action plan focused on staff training, clearer processes, and accountability as noted below. •A training session was conducted for newly hired staff to ensure understanding of the FFATA reporting requirements. •Staff were cross trained to improve the workflow and reduce disruptions during periods of staff shortages or competing priorities. •The Division has updated its FFATA procedures, and a budget analyst has been assigned to each grant to begin the FFATA reporting process. •The Division is completing fiscal year 2026 FFATA reporting to bring all reporting current as part of ongoing operations. •The Division or designee will oversee the reporting process to ensure accuracy and timely reporting. Anticipated Completion Date: June 30, 2026.
View Audit 394732
Finding 1187037 (2025-022)
Material Weakness 2025
State of North Carolina
NC
Eligibility
Deficiencies In the TANF Eligibility Determination Process The Division of Child Development and Early Education (Division) will provide targeted technical assistance and training to the county in error. The Division will also analyze the error and incorporate this error as a training item in future...
Deficiencies In the TANF Eligibility Determination Process The Division of Child Development and Early Education (Division) will provide targeted technical assistance and training to the county in error. The Division will also analyze the error and incorporate this error as a training item in future regional meetings/trainings for all counties. Anticipated Completion Date: December 31, 2026.
View Audit 394732
Finding 1187036 (2025-021)
Material Weakness 2025
State of North Carolina
NC
Reporting
FFATA Reporting Not Completed See 2025-019 for the Corrective Action Plan.
FFATA Reporting Not Completed See 2025-019 for the Corrective Action Plan.
View Audit 394732
Finding 1187035 (2025-020)
Material Weakness 2025
State of North Carolina
NC
Maintenance of Effort Report Certification Not Completed See 2025-018 for the Corrective Action Plan.
Maintenance of Effort Report Certification Not Completed See 2025-018 for the Corrective Action Plan.
View Audit 394732
Finding 1187034 (2025-019)
Material Weakness 2025
State of North Carolina
NC
Subrecipient Monitoring Reporting
FFATA Reporting Not Completed The Division of Aging has initiated the development of a comprehensive contingency plan that includes: Actions Taken: All subrecipient grant notices for the audited period were uploaded to the FFATA Subaward Reporting System (FSRS). Planned Actions: • Development and Im...
FFATA Reporting Not Completed The Division of Aging has initiated the development of a comprehensive contingency plan that includes: Actions Taken: All subrecipient grant notices for the audited period were uploaded to the FFATA Subaward Reporting System (FSRS). Planned Actions: • Development and Implementation of Standard Operating Procedures (SOPs) including detailed instructions and timelines for identifying applicable subawards and completing FFATA reporting in FSRS. • Cross-training of staff across sections regarding requirements and expectations for FFATA reporting. • Establishing a system to track subawards, monitor reporting deadlines, and verify timely submissions. The Division Director (or their appointed designee) and Section Chief of Planning will oversee implementation and conduct reviews to ensure ongoing compliance. Anticipated Completion Date: June 30, 2026.
View Audit 394732
Finding 1187033 (2025-018)
Material Weakness 2025
State of North Carolina
NC
Eligibility Reporting Internal Control / Segregation of Duties
Maintenance of Effort Report Certification Not Completed The Division of Aging acknowledges the importance of ensuring timely certification and submission of required reports. The Division will complete the following: • Development and Implementation of Standard Operating Procedures (SOPs) including...
Maintenance of Effort Report Certification Not Completed The Division of Aging acknowledges the importance of ensuring timely certification and submission of required reports. The Division will complete the following: • Development and Implementation of Standard Operating Procedures (SOPs) including identification of responsible parties (positions), detailed instructions and guidance for preparing, certifying, and submitting the MOE report. • Cross-training of staff to ensure continuity of reporting functions during periods of turnover or absence. The Division’s Director (or their designee) and the Section Chief of Planning will oversee implementation and conduct reviews to ensure ongoing compliance. Anticipated Completion Date: August 2026.
View Audit 394732
Finding 1187032 (2025-017)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
Student Enrollment Status Reporting Errors See 2025-009 for the Corrective action Plan.
Student Enrollment Status Reporting Errors See 2025-009 for the Corrective action Plan.
View Audit 394732
Finding 1187031 (2025-016)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Subrecipient Monitoring Eligibility
Financial Assistance Disbursed in Excess of Student Eligibility Modified existing report to include the identification of students with dependent status and independent level loans in the absence of a Parent PLUS denial. Added weekly task to Loan Processing calendar to include the review of report. ...
Financial Assistance Disbursed in Excess of Student Eligibility Modified existing report to include the identification of students with dependent status and independent level loans in the absence of a Parent PLUS denial. Added weekly task to Loan Processing calendar to include the review of report. Corrective Action was Completed on: August 25, 2025.
View Audit 394732
Finding 1187030 (2025-015)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
No Internal Controls Over Student Enrollment Status Reporting See 2025-008 for the Corrective Action Plan.
No Internal Controls Over Student Enrollment Status Reporting See 2025-008 for the Corrective Action Plan.
View Audit 394732
Finding 1187029 (2025-014)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
No Internal Controls Over Student Enrollment Status Reporting See 2025-007 for the Corrective Action Plan.
No Internal Controls Over Student Enrollment Status Reporting See 2025-007 for the Corrective Action Plan.
View Audit 394732
Finding 1187028 (2025-013)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Subrecipient Monitoring Eligibility
Financial Assistance Disbursed in Excess of Student Eligibility In September and October 2025, the Director of Student Financial Aid reminded the team members of the mandatory process step which requires them to review each student’s loan history in the NSLDS (National Student Loan Data System) and ...
Financial Assistance Disbursed in Excess of Student Eligibility In September and October 2025, the Director of Student Financial Aid reminded the team members of the mandatory process step which requires them to review each student’s loan history in the NSLDS (National Student Loan Data System) and place a copy of the NSLDS history in the student’s financial aid file as evidence of their review. A review process to confirm compliance was implemented in the fall 2025 semester. An Assistant Director in the Office of Student Financial Aid is responsible for performing audits of our internal files to confirm that the NSLDS reviews are documented. The Assistant Director also provides remediation to any team member whose records are not in compliance. The University has already repaid the over-award amount. Corrective action was completed on: October 29, 2025.
View Audit 394732
Finding 1187027 (2025-012)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
Student Enrollment Status Reporting Errors See 2025-006 for the Corrective Action Plan.
Student Enrollment Status Reporting Errors See 2025-006 for the Corrective Action Plan.
View Audit 394732
Finding 1187026 (2025-011)
Material Weakness 2025
State of North Carolina
NC
Financial Assistance Disbursed Without Evaluating Satisfactory Academic Progress See 2025-005 for the Corrective Action Plan.
Financial Assistance Disbursed Without Evaluating Satisfactory Academic Progress See 2025-005 for the Corrective Action Plan.
View Audit 394732
Finding 1187025 (2025-010)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
No Internal Controls Over Student Enrollment Status Reporting See 2025-003 for the Corrective Action Plan.
No Internal Controls Over Student Enrollment Status Reporting See 2025-003 for the Corrective Action Plan.
View Audit 394732
Finding 1187024 (2025-009)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Subrecipient Monitoring Eligibility
Student Enrollment Status Reporting Errors Collaborate with UNCG Information Technology Services (ITS) to create an automated process to correctly report enrollment status changes with appropriate status dates to the National Student Loan Database System (NSLDS) via the National Clearinghouse (NSC) ...
Student Enrollment Status Reporting Errors Collaborate with UNCG Information Technology Services (ITS) to create an automated process to correctly report enrollment status changes with appropriate status dates to the National Student Loan Database System (NSLDS) via the National Clearinghouse (NSC) when a student adds, drops, or withdraws from one or more (but not all) courses. Develop written policies and procedures that detail how the automated processing reports data, how manual updates are made, how to respond to error reports, and when/how to test samples at NSC and NSLDS on a recurring basis to ensure the process is working as intended. The written policies and procedures will identify key positions within the University Registrar Office and Office of Financial Aid and Scholarships and what each position is responsible for including regularly testing enrollment reporting to ensure NSC and NSLDS are up to date based on the latest enrollment reporting file. Anticipated Completion Date: April 3, 2026.
View Audit 394732
Finding 1187023 (2025-008)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Subrecipient Monitoring Eligibility § 200.303
No Internal Controls Over Student Enrollment Status Reporting Financial Aid Control for NSLDS Enrollment Reporting: •Enrollment is reported via the National Student Clearinghouse by the Registrar. •Financial Aid Staff (Associate Director of Financial Aid) will pull a list of enrolled students for th...
No Internal Controls Over Student Enrollment Status Reporting Financial Aid Control for NSLDS Enrollment Reporting: •Enrollment is reported via the National Student Clearinghouse by the Registrar. •Financial Aid Staff (Associate Director of Financial Aid) will pull a list of enrolled students for the semester and create a sample population for the control check. •Financial Aid Staff (Associate Director of Financial Aid) will Ched each individual student in the Enrollment section of NSLDS to ensure the student's enrollment status has been reported correctly. •Financial Aid Staff (Associate Director of Financial Aid) will perform this check 2-3 weeks after census each semester and document the check in the quality control folder in the shared drive. Corrective Action was Completed on: December 5, 2025.
View Audit 394732
Finding 1187022 (2025-007)
Material Weakness 2025
State of North Carolina
NC
Student Financial Aid Subrecipient Monitoring Eligibility
No Internal Controls Over Student Enrollment Status Reporting Like many schools, ECU relies on the National Student Clearinghouse (NSC) to submit student enrollment status data to the NSLDS (National Student Loan Data System). In response to the audit recommendation, an Assistant Director in the Off...
No Internal Controls Over Student Enrollment Status Reporting Like many schools, ECU relies on the National Student Clearinghouse (NSC) to submit student enrollment status data to the NSLDS (National Student Loan Data System). In response to the audit recommendation, an Assistant Director in the Office of Student Financial Aid has been assigned to regularly review automated reports that identify students whose data in the ECU, NSC, and NSLDS databases doesn’t match. (This task was not completed during the audit period due to position vacancies.) When a student is identified on the error report, the Assistant Director reviews the data in ECU’s student system and the NSLDS to determine the differences and the root cause of the problem. The Financial Aid Office and/or Registrar Office then takes corrective action to ensure the NSLDS record and ECU’s record matches. Corrective action was completed on: October 1, 2025.
View Audit 394732
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