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Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: A...
Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Activities Allowable or Unallowed and Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: HCA’s Ventura County Public Health (VCPH) Management agrees with the recommendation to strengthen the established policies and procedures to ensure all timecards consistently document evidence of supervisor approval. View of Responsible Officials and Corrective Action: The timesheet identified during this audit were submitted in the County’s payroll system prior to the completion of the 2024 fiscal year audit and related finding 2024-003; therefore, the related corrective actions had not yet been implemented at the time of submission. In response to the prior year’s finding, VCPH Management implemented enhanced controls to ensure compliance with timecard approval requirements moving forward from that date. Payroll staff now sends reminder notifications to supervisors, managers, and VCPH Management before and after each pay period closing to identify and resolve unapproved timecards. Management has also reinforced expectations through additional training for supervisors and managers. When a primary supervisor is unavailable, the established alternate approver process will be used to ensure timely approvals. VCPH Management will continue monitoring compliance with these procedures, and these requirements will be reviewed again with all supervising staff at the next scheduled WIC Supervisor Meeting. Name of Responsible Persons: Laura Flores, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: May 1, 2025 – Instructions were provided to all supervisors at the WIC Supervisor Team Meeting May 7, 2026 – Timecard instructions will again be discussed at the WIC Supervisor Team Meeting
Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Procurement and Su...
Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control over Compliance and Instance of Non-Compliance Department’s Management Response: Ventura County Health Care Agency (HCA) management agrees with the recommendation for the County to strengthen its policies and procedures to ensure that the verification of the debarment and suspension is documented and retained, the history of procurement transactions is documented and retained in its official record, and that contracts include all applicable provisions of 2 CFR 200 Appendix II. View of Responsible Officials and Corrective Action: HCA Management will implement documentation procedures to support the evaluation and selection of vendors. These procedures will include but are not limited to, ensuring that debarment and suspension verifications are properly documented and retained, procurement transaction histories are maintained in official records, and all contracts include the applicable provisions required under 2 CFR 200 Appendix II. Name of Responsible Persons: Mike Taylor, HCA CFO John Fankhauser, HCA Director Implementation Date: March 2026 – Add documentation of suspension and debarment check for applicable contracts April 2026 – Include applicable provisions described in 2 CFR 200 Appendix II to contracts
The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete tim...
The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete timely vouchers will occur. This new process will enable the fiscal employees responsible for vouchering to complete their functions in a timely manner.
KEDREN'S PRIMARY CARE CLINICAL MANAGEMENT HAS IMPLEMENTED SEVERAL STEPS TO ENSURE THAT THE PATIENTS ARE BILLED PROPERLY IN ACCORDANCE WITH THE SLIDING FEE SCHEDULE. THESE CHANGES WILL BE IMPLEMENTED AND MONITORED
KEDREN'S PRIMARY CARE CLINICAL MANAGEMENT HAS IMPLEMENTED SEVERAL STEPS TO ENSURE THAT THE PATIENTS ARE BILLED PROPERLY IN ACCORDANCE WITH THE SLIDING FEE SCHEDULE. THESE CHANGES WILL BE IMPLEMENTED AND MONITORED
Need Analysis Planned Corrective Action: The institution is moving to automated loan packaging by the Power FAIDS financial aid management system, which packages the loan based on grade level and remaining unmet financial need. Therefore, if a student’s remaining need is less than the available subs...
Need Analysis Planned Corrective Action: The institution is moving to automated loan packaging by the Power FAIDS financial aid management system, which packages the loan based on grade level and remaining unmet financial need. Therefore, if a student’s remaining need is less than the available subsidized eligibility, the system will only package up to the remaining need. Furthermore, as a second quality assurance check, a rule has been written in the PowerFAIDS financial aid management system that will flag any student that has been awarded sub over need. Person Responsible for Corrective Action Plan: Justin Pichey, Director of Financial Aid Anticipated Date of Completion: This has already been implemented for fiscal year 2026-2027.
Credit Balances Held Beyond Payment Period Planned Corrective Action: Ohio Christian University has implemented procedures to ensure that all Title IV credit balances are identified and released to students within 14 days of the credit balance occurring, in compliance with federal regulations. The F...
Credit Balances Held Beyond Payment Period Planned Corrective Action: Ohio Christian University has implemented procedures to ensure that all Title IV credit balances are identified and released to students within 14 days of the credit balance occurring, in compliance with federal regulations. The Financial Aid Office will run weekly credit balance reports following each disbursement to identify any student accounts with a Title IV credit balance. These reports will be reviewed jointly by the Financial Aid and Student Accounts offices to confirm eligibility and authorize timely refunds. As an ongoing quality assurance measure, supervisory review will be conducted monthly to verify compliance with the 14-day requirement, and any exceptions will be documented and addressed immediately. Staff training has been enhanced to reinforce regulatory requirements and internal timelines related to credit balance processing. Person Responsible for Corrective Action Plan: Justin Pichey, Director of Financial Aid & Chelsie Hedrick, Senior Accountant Anticipated Date of Completion: This was implemented starting with the Spring 2026 semester.
Finding Number: 2025‐004 Program Name/Assistance Listing Title: Indian School Equalization Program, Special Education Cluster (IDEA) Assistance Listing Number: 84.425, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The Schoo...
Finding Number: 2025‐004 Program Name/Assistance Listing Title: Indian School Equalization Program, Special Education Cluster (IDEA) Assistance Listing Number: 84.425, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School lacked adequate internal controls over disbursements, journal entries, and payroll. - Efforts to maintain proper supporting documentation for various transactions must improve.Staff training to highlight the importance of following procedures and maintaining supporting documentation for all transactions has already occurred and will be held multiple times in the future. - Two current employees have unusual employment status that makes recalculating their pay difficult; they are part‐time, but on salary.
Finding Numbers: 2025‐003, 2024‐003, 2023‐003 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Numbers: 84.425 Contact Person: Holena Lebron, Superintendent An􀆟cipated Completion Date: June 30, 2026 Planned Corrective Action: The School has not been abl...
Finding Numbers: 2025‐003, 2024‐003, 2023‐003 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Numbers: 84.425 Contact Person: Holena Lebron, Superintendent An􀆟cipated Completion Date: June 30, 2026 Planned Corrective Action: The School has not been able to devote proper resources and training to ensure capital assets are accurate and up to date. - The staff member assigned to make improvements in this area since the fiscal year 2023‐24 audit is no longer employed by the School. Additional staff and training are needed. - The School will seek to replace needed staff and reassign duties regarding the tracking of capital assets, including the assigning of identification numbers and inventory procedures.
Finding Numbers: 2025‐002, 2024‐002 Program Name/Assistance Listing Titles: Indian School Equalization; Administrative Cost Grants for Indian Schools, Special Education Cluster (IDEA) Assistance Listing Numbers: 15.042; 15.046, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Complet...
Finding Numbers: 2025‐002, 2024‐002 Program Name/Assistance Listing Titles: Indian School Equalization; Administrative Cost Grants for Indian Schools, Special Education Cluster (IDEA) Assistance Listing Numbers: 15.042; 15.046, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School’s internal controls over procurement of goods and services were not adequate. - A change in office staff just before the audit visit made finding documentation related to procurement difficult. Efforts to improve in this area have been made and will continue to be a focus of the administration. Procurement procedures are in place and are being followed, but record keeping remains a challenge. A new hire in this area with training emphasis is needed.
Finding Numbers: 2025‐001, 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School did not complete character ...
Finding Numbers: 2025‐001, 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School did not complete character reinvestigations timely for all employees. - An internal review identified that employee suitability determinations and five‐year reinvestigations were not consistently tracked. - To address this, the administration will review all personnel files to identify employees who are due or overdue for reinvestigation. Any overdue determinations will be completed immediately. A tracking system will be implemented to monitor the five‐year requirement and ensure reinvestigations are completed on time moving forward. Periodic file reviews will also be conducted to maintain compliance.
We will review procedures and plan to make changes to improve internal control when possible.
We will review procedures and plan to make changes to improve internal control when possible.
We will review procedures and plan to make changes to improve internal control when possible.
We will review procedures and plan to make changes to improve internal control when possible.
Finding 1204849 (2025-002)
Material Weakness 2025
NAMI Chicago acknowledges the finding and has revised the finance policy as of January 1, 2026 to clearly define micro-purchase thresholds and procedures for micropurchases, simplified acquisition thresholds and procedures for simplified acquisitions, formal procurement methods for use when transact...
NAMI Chicago acknowledges the finding and has revised the finance policy as of January 1, 2026 to clearly define micro-purchase thresholds and procedures for micropurchases, simplified acquisition thresholds and procedures for simplified acquisitions, formal procurement methods for use when transactions exceed acquisition threshold and noncompetitive procurement methods. Management will monitor procurement activity for compliance with the updated policy.
Finding 1204848 (2025-001)
Material Weakness 2025
NAMI Chicago acknowledges the finding regarding documentation of approvals for expenses charged to federal awards. The exceptions identified occurred during the first half of the fiscal year, prior to the January 1, 2025, implementation of our enhanced Internal Control and Disbursement Policy develo...
NAMI Chicago acknowledges the finding regarding documentation of approvals for expenses charged to federal awards. The exceptions identified occurred during the first half of the fiscal year, prior to the January 1, 2025, implementation of our enhanced Internal Control and Disbursement Policy developed in direct response to the FY24 audit recommendations, which were finalized and communicated in early 2025. Since January 1, 2025, NAMI Chicago has successfully implemented a mandatory digital approval workflow for all grant-funded expenditures to ensure contemporaneous documentation. Management is confident that these strengthened protocols, which were fully operational for the latter half of FY2025 and continue to date, have resolved the underlying issue. We expect no further instances of this finding in future audit cycles.
Finding 2025-001 Condition The University did not notify the National Student Loan Data System (NSLDS) in a timely manner for four students with status changes. Corrective Action Plan 1. Finding: Incorrect Status Date Reported to NSC/NSLDS for a withdrawn student Corrective Actions: • Root Cause Ana...
Finding 2025-001 Condition The University did not notify the National Student Loan Data System (NSLDS) in a timely manner for four students with status changes. Corrective Action Plan 1. Finding: Incorrect Status Date Reported to NSC/NSLDS for a withdrawn student Corrective Actions: • Root Cause Analysis: A review was conducted to determine why NSC/NSLDS received the incorrect date despite Colleague displaying the correct withdrawal date of 3/20/2025. The analysis confirmed that the Colleague reporting process pulls the date from the course drop/withdrawal field rather than the student status withdrawal date screen. According to system documentation, “SITX determines the enrollment status, enrollment status start date, and the anticipated graduation date for the students included in the extract. If the enrollment status changes during the reporting period since the last census date, the status change date is calculated from schedule changes and hiatus record information.” • Process Improvement: o Staff have been instructed to ensure that all relevant screens reflect the correct status change date prior to reporting. o Documentation is being developed outlining the withdrawal process workflow, including all screens requiring updates. This will promote consistency and serve as a reference for future staff transitions. 2. Finding: Failure to Report Three Graduates to NSLDS Within the 60 Day Requirement Corrective Actions: • Root Cause Analysis: The University Registrar contacted the NSC to investigate the delay. Although the NSC Degree Verify file was submitted within the required timeframe, it was determined that the “G Not Applied” process on the NSC site was not completed promptly by Registrar’s Office staff, resulting in the late NSLDS reporting. • Process Redesign: The University Registrar is working with Gannon IT Services to develop a “Graduates Only” reporting process directly from Colleague. This enhancement will eliminate reliance on the NSC “G Not Applied” step, which has been a recurring compliance challenge. This new process will be implemented no later than July 1, 2026. Until then, the “G Not Applied” list will be processed within 10 days of processing availability (at times the G Not Applied cannot be updated while an Enrollment file submission is pending acceptance). • Proactive Audit Measures: Given the significant staffing transitions and shifts in reporting responsibilities over the past year, an internal audit of the 2025–2026 reporting completed to date is underway, in collaboration with the NSC Audit Department, to determine the full extent of any additional reporting deficiencies that may have carried into the new academic year. 3. As previously stated in the Summary Schedule of Prior Audit Findings for the Year-Ended June 30, 2024 Update, the following corrective actions are being initiated: • Additional staff have been designated to ensure that at least three individuals possess the knowledge and system access required to submit reports and process corrections. • All designated staff are required to complete NSC-provided training to ensure full understanding of reporting requirements and procedures. • Each staff member must submit test reports and review resulting errors using the NSC test submission process, working closely with assigned NSC analysts to demonstrate competency in accurate reporting and effective error resolution. Name(s) of Contact Person(s) Responsible o Barbara Helms, University Registrar – primary responsibility for enrollment reporting submissions, back-up for G reporting o Heidi Thomas, Processing and Data Specialist – assists with enrollment error report cleanup, secondary for enrollment reporting submissions, additional back-up for G reporting o Ashley Dinger, Academic Records and Graduation Specialist – primary responsibility of the G reporting, additional back-up for enrollment reporting. • Although documentation exists from the previous corrective action plan, it has been determined that it is not sufficiently detailed. New documentation is being developed to ensure that any individual responsible for these processes in the future has the necessary tools and guidance to meet all regulatory requirements. Estimated timeline for corrective action to be implemented: April 2026
FINDING 2025-007 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We have revised our award period start and end dates to align or fall within range of our loan period code start and end dates when reporting to COD. This alignment ensures that all reported disb...
FINDING 2025-007 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We have revised our award period start and end dates to align or fall within range of our loan period code start and end dates when reporting to COD. This alignment ensures that all reported disbursements meet federal timing requests and reduces the risk of COD rejects or compliance findings. Anticipated Completion Date: March 31, 2026
FINDING 2025-006 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: To resolve the finding of loan period academic end dates being inaccurately reported, we now utilize system forms that allow us to identify and batch-correct any student record with incorrect dat...
FINDING 2025-006 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: To resolve the finding of loan period academic end dates being inaccurately reported, we now utilize system forms that allow us to identify and batch-correct any student record with incorrect dates. This process enhances data accuracy, ensures proper reporting, prevents COD rejects and reduces the risk of future compliance issues. Anticipated Completion Date: Already completed
FINDING 2025-005 Name of Responsible Individual: Chad Wick, Director of Financial Aid Corrective Action: We have implemented a new Quality Assurance Measure for Auditing all students with a C-Flag. The process begins with the FA advisor team. They are responsible for ensuring all documents have been...
FINDING 2025-005 Name of Responsible Individual: Chad Wick, Director of Financial Aid Corrective Action: We have implemented a new Quality Assurance Measure for Auditing all students with a C-Flag. The process begins with the FA advisor team. They are responsible for ensuring all documents have been received and all steps have been completed to clear the C-Flag. In Colleague the advisor will then mark the file is ready for audit. Chad Wick, Director, Financial aid or Brandon Rhone, Systems Administrator, will review all documents and steps needed to clear C-Flag and then update the communication code to audited and make any adjustments if needed to the FAFSA. Anticipated Completion Date: Already completed
FINDING 2025-004 Name of Responsible Individual: Chad Wick, Director of Financial Aid, and Brandon Rhone, Systems Administrator Corrective Action: We will implement a second check process after R2T4 has been calculated to ensure the correct dates are being used. Chad Wick, Director, Financial Aid wi...
FINDING 2025-004 Name of Responsible Individual: Chad Wick, Director of Financial Aid, and Brandon Rhone, Systems Administrator Corrective Action: We will implement a second check process after R2T4 has been calculated to ensure the correct dates are being used. Chad Wick, Director, Financial Aid will conduct the initial calculating of R2T4 on a weekly basis. Brandon Rhone, Systems Administrator, will review all calculations prior to processing them in Colleague. Anticipated Completion Date: March 31, 2026
FINDING 2025-003 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We implemented a process which assigns communications management codes based on transmittal activity of each federal direct loan. On the same day a loan is disbursed, our system applies the appro...
FINDING 2025-003 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We implemented a process which assigns communications management codes based on transmittal activity of each federal direct loan. On the same day a loan is disbursed, our system applies the appropriate code to the student record. These codes are then automatically selected for the correct loan disbursement notification to be sent either to the student or parent based on the federal loan type. Anticipated Completion Date: Already completed
FINDING 2025-002 Name of Responsible Individual: Chad Wick, Director of Financial Aid Corrective Action: We have implemented a new Quality Assurance Measure for Auditing all students selected for verification. The process begins with the FA advisor team. They are responsible for ensuring all documen...
FINDING 2025-002 Name of Responsible Individual: Chad Wick, Director of Financial Aid Corrective Action: We have implemented a new Quality Assurance Measure for Auditing all students selected for verification. The process begins with the FA advisor team. They are responsible for ensuring all documents have been received and verification has been completed. In Colleague the advisor will then mark the file is ready for audit. Chad Wick, Director, Financial aid or Brandon Rhone, Systems Administrator, will review all documents and verification steps and then update the verification status to verified and the communication code to audited. Anticipated Completion Date: Already completed
FINDING 2025-001 Name of Responsible Individual: Mary Beth Schiller-Schwenke, Chief Financial Officer and Controller Corrective Action: The Federal Pell Grant Program instances resulted from reversals of student awards. The Business Office routinely monitors the general ledger for award transactions...
FINDING 2025-001 Name of Responsible Individual: Mary Beth Schiller-Schwenke, Chief Financial Officer and Controller Corrective Action: The Federal Pell Grant Program instances resulted from reversals of student awards. The Business Office routinely monitors the general ledger for award transactions, however, reversals of student aid awarded late in the academic term can be missed. The Financial Aid Office will be responsible for notifying the Business Office when they initiate award reversals that necessitate a refund. The Business Office has updated procedures so that the related general ledger accounts are reviewed no less than once per week for the full year. In addition to ongoing monitoring of the related general ledger accounts, the Business Office will also create automated reporting to notify staff of the pending account balances. Anticipated Completion Date: April 30, 2026
Injury Prevention and Control Research and State and Community Based Programs– Assistance Listing No. 93.136 Community Programs to Improve Minority Health Grant– Assistance Listing No. 93.137 Ending the HIV Epidemic in the U.S. – Ryan White HIV/AIDS Program Parts A and B Assistance Listing No. 93.68...
Injury Prevention and Control Research and State and Community Based Programs– Assistance Listing No. 93.136 Community Programs to Improve Minority Health Grant– Assistance Listing No. 93.137 Ending the HIV Epidemic in the U.S. – Ryan White HIV/AIDS Program Parts A and B Assistance Listing No. 93.686 Recommendation: We recommend that management implement formal policies and procedures to ensure FFATA reporting requirements are identified, tracked, and reported timely for all applicable subawards. This should include documented review procedures and monitoring controls to ensure FFATA reports are submitted accurately and within required deadlines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BPHC will update our FFATA Reporting Standard Operating Procedures (SOP) to include tighter controls that ensure that FFATA reporting requirements are more clearly identified, tracked and reported timely for all applicable subawards. The updated SOP will document the revised procedures and require a biweekly or monthly sign off from the Director of the Post-Award Grant Accounting to ensure that our FFATA reporting is accurate and on time going forward. Name(s) of the contact person(s) responsible for corrective action: Jose A. Hernandez and Steve Simmons Planned completion date for corrective action plan: Prior to June 30, 2026
Name: T.P. White Complex, Inc., d/b/a Traskwood Complex, Inc. Contact: Patricia Walker, Chief Financial Officer Contact Phone Number: 501-982-0528 Audit Period Ending: June 30, 2025 Anticipated Completion Date: May 31, 2026 Finding 2025-001: Upon renewal of its Project Rental Assistance Contract (PR...
Name: T.P. White Complex, Inc., d/b/a Traskwood Complex, Inc. Contact: Patricia Walker, Chief Financial Officer Contact Phone Number: 501-982-0528 Audit Period Ending: June 30, 2025 Anticipated Completion Date: May 31, 2026 Finding 2025-001: Upon renewal of its Project Rental Assistance Contract (PRAC) on November 30, 2024, the Project did not remit residual receipts in excess of $250 per unit to HUD as required by HUD guidance. Management’s Response and Planned Corrective Actions: Subsequent to year end, management engaged in discussions with HUD and intends to identify eligible Project needs and submit a HUD 9250 request to use the excess residual receipts in accordance with HUD Handbook 4350.1, Chapter 25, Section 25 9. Approval of such a request is at HUD’s discretion.
Name: Mulberry Place, Inc. Contact: Patricia Walker, Chief Financial Officer Contact Phone Number: 501-982-0528 Audit Period Ending: June 30, 2025 Anticipated Completion Date: May 31, 2026 Finding 2025-001: Upon renewal of its Project Rental Assistance Contract (PRAC) on July 31, 2024, the Project d...
Name: Mulberry Place, Inc. Contact: Patricia Walker, Chief Financial Officer Contact Phone Number: 501-982-0528 Audit Period Ending: June 30, 2025 Anticipated Completion Date: May 31, 2026 Finding 2025-001: Upon renewal of its Project Rental Assistance Contract (PRAC) on July 31, 2024, the Project did not remit residual receipts in excess of $250 per unit to HUD as required by HUD guidance. Management’s Response and Planned Corrective Actions: Subsequent to year end, management engaged in discussions with HUD and intends to identify eligible Project needs and submit a HUD 9250 request to use the excess residual receipts in accordance with HUD Handbook 4350.1, Chapter 25, Section 25 9. Approval of such a request is at HUD’s discretion.
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