Corrective Action Plans

Finding 1175686 (2025-004)

Material Weakness 2025

Iberia Comprehensive Community Health Center

LA

Management has is currently implementing procedures to have all staff responsible for sliding fee eligibility trained in areas of converting pay information to monthly or annual income for sliding fee determinations. Management will also implement quality review processes to ensure that correct pay ...

Management has is currently implementing procedures to have all staff responsible for sliding fee eligibility trained in areas of converting pay information to monthly or annual income for sliding fee determinations. Management will also implement quality review processes to ensure that correct pay frequency and conversion factors are used.

View Audit 389534

Finding 1175685 (2025-003)

Material Weakness 2025

Iberia Comprehensive Community Health Center

LA

Management has currently implemented procedures to communicate the approved current sliding fee schedule to the appropriate personnel.

View Audit 389534

Finding 1175684 (2025-002)

Material Weakness 2025

Iberia Comprehensive Community Health Center

LA

Cash Management

Management has currently implemented procedures for grant funded expenditures to ensure that complete documentation supporting the funds requests are available and at the time of the drawdown of the grant funds.

View Audit 389534

Finding 1175683 (2025-001)

Material Weakness 2025

Millville Public Charter School

NJ

School Nutrition Programs

Reviewing the fund balance monthly and purchasing necessary supplies and staff to keep the balance down.

View Audit 389519

Finding 1175672 (2025-001)

Material Weakness 2025

Margaret B. MacK Supportive Housing Corporation Hud Proj. #017-Hd038

CT

Internal Control / Segregation of Duties Significant Deficiency

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management review the rates used to calculate management fees to ensure that they agree to the agreed upon percentages outlined in the agreem...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management review the rates used to calculate management fees to ensure that they agree to the agreed upon percentages outlined in the agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that calculated management fees match the agreed upon rates. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Completed on January 31, 2026.

View Audit 389507

Finding 1175670 (2025-002)

Material Weakness 2025

Continuum of Care, Inc. and Affiliates

CT

Internal Control / Segregation of Duties Significant Deficiency

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: Department of Housing and Urban Development requires any surplus funds in the project funds account at the end of the fiscal year to be deposited in a federally insured account within 6...

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: Department of Housing and Urban Development requires any surplus funds in the project funds account at the end of the fiscal year to be deposited in a federally insured account within 60 days following the end of the fiscal year. Condition: As of June 30, 2024, Continuum Supportive Housing of West Hartford, Inc. has a surplus cash of $50,759. The required deposit into a residual receipt account was not made within 60 days following the end of the fiscal year. Questioned costs: None Context: We reviewed the surplus cash calculation noting that the Project has a surplus cash of $50,759 at the end of the fiscal year 24. Surplus cash should have been deposited within 60 days following the end of the fiscal year. Cause: This was an oversight by management. Effect: The required deposit was not made as required by the Department of Housing and Urban Development. Repeat Finding: Yes Recommendation: We recommend management to ensure that required deposits are made 60 days following the fiscal year-end. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Required deposit made by March 31, 2025. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: January 31, 2026.

View Audit 389506

Finding 1175668 (2025-001)

Material Weakness 2025

Continuum of Care, Inc. and Affiliates

CT

Significant Deficiency Internal Control / Segregation of Duties

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon p...

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon performing testing over payroll disbursements, we noted that there was no approval of the timesheets for the payroll disbursements tested. Questioned costs: None Context: The timesheet for 1 out of 5 payroll disbursements tested was not properly approved by the property manager. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over payroll disbursements. Effect: There is no evidence of proper approval of payroll disbursement. Repeat Finding: Yes Recommendation: We recommend that management strengthen controls over review of payroll. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Although other controls assist to safeguard and mitigate compensation errors, the property manager will ensure that all time sheets are properly approved prior to payment, and if necessary the VP of Operations or the President of the managing agent will provide further assurance of internal controls through reviews. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: January 31, 2026.

View Audit 389506

Finding 1175666 (2025-004)

Material Weakness 2025

Loyalsock Township School District

PA

School Nutrition Programs

Child Nutrition Cluster, National School Lunch Program – Assistance Listing 10.555; passed through the Pennsylvania Department of Education; Grant Period – Year Ended June 30, 2025 Significant deficiency: See deficiency 2025-002 listed below. 2025-002. FOOD SERVICE RECEIVABLES Planned Corrective Act...

Child Nutrition Cluster, National School Lunch Program – Assistance Listing 10.555; passed through the Pennsylvania Department of Education; Grant Period – Year Ended June 30, 2025 Significant deficiency: See deficiency 2025-002 listed below. 2025-002. FOOD SERVICE RECEIVABLES Planned Corrective Action: The Staff Accountant Amber Whited will review receipts after year end to ensure receivables are accurately identified and recorded as receivables. Person Responsible: Staff Accountant (Amber Whited) Anticipated Completion date: Immediately

View Audit 389501

Finding 1175664 (2025-001)

Material Weakness 2025

Behavioral Health Solutions of South Texas

TX

Reporting § 200.329

Finding #2025-001: Type of Finding: Other Finding Responsible Person Abigail Ramos – Program Director Implementation Date January 12, 2026 Views of responsible officials and planned corrective actions Management disagrees with the finding as the assigned Grant Program Official (GPO) with SAMHSA acce...

Finding #2025-001: Type of Finding: Other Finding Responsible Person Abigail Ramos – Program Director Implementation Date January 12, 2026 Views of responsible officials and planned corrective actions Management disagrees with the finding as the assigned Grant Program Official (GPO) with SAMHSA accepted and approved the report and did not note this singular incident as a finding nor did the GPO find BHSST as being non-compliant. Consideration was extended due to the change in Program Director and the impact of the government shutdown affecting access to the assigned GPO. Change in key personnel required prior approval by SAMHSA before the new Program Director could begin working on the project. The new Program Director did have limited access to the assigned GPO due to the impact of the government shutdown and misunderstood that an extension filed was extended to the eRA Commons report versus this report. Reporting deadlines are met by submitting reports prior to the deadline. Challenges that led to the delayed submission have been remedied as clarification was obtained regarding the submission deadlines and process for requesting an extension for both the annual performance and eRA Commons reports. Further management notes this report did not impact the program's ability to continue nor delay any fiscal processes and is not considered a finding by the funder. Auditor Response Based on review and consideration of documentation and responses provided by Management, no documented evidence was available to address the finding of noncompliance.

View Audit 389500

Finding 1175663 (2025-001)

Material Weakness 2025

Marana Health Center, INC

AZ

The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. o Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self...

The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. o Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self-declaration of income and family size. The front office will verify the application, determine the scale for which the patient qualifies, and verify with the Center’s practice management system. The lead biller will review all uploaded documents and approve the sliding fee in real time. o Additional training will take place with front desk personnel. The corrective action outlined above will be monitored on an ongoing basis. The CFO and the Controller will oversee the implementation and report progress to the CEO and Board . Regular internal reviews and reconciliations will be conducted to ensure continued compliance with internal controls and federal requirements.

View Audit 389495

Finding 1175662 (2025-004)

Material Weakness 2025

Florida College, INC

FL

Student Financial Aid Significant Deficiency

Incorrect Pell Calculations Planned Corrective Action: Management acknowledges the error in calculation. As a result of change in student information software and financial aid software in conjunction with manual processes employed during transition of academic years, timing of review and misinterpr...

Incorrect Pell Calculations Planned Corrective Action: Management acknowledges the error in calculation. As a result of change in student information software and financial aid software in conjunction with manual processes employed during transition of academic years, timing of review and misinterpretation of Summer Pell regulations, this error was not identified timely. This may have carried over to the subsequent term. Management receives this as opportunity to improve upon processes to ensure higher visibility and oversight to reduce any further risk making certain to align policies with DOE. Person Responsible for Corrective Action Plan: Kristina Elmore, Director of Financial Aid Anticipated Date of Completion: February 2026

View Audit 389486

Finding 1175661 (2025-001)

Material Weakness 2025

Coastal Carolina University

SC

Student Financial Aid Reporting

U.S. Department of Education Coastal Carolina University respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit Period: July 1, 2024 - June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are number...

U.S. Department of Education Coastal Carolina University respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit Period: July 1, 2024 - June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FINANCIAL STATEMENT AUDIT None noted FINDINGS - FEDERAL AWARD PROGRAMS AUDITS Department of Education 2025-001 National Student Loan Data System (NSLDS) Reporting Recommendation: We recommend the University review and update its policies and procedures to ensure all enrollment status changes are reviewed and submitted in a timely manner in accordance with federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Plan: The University reviewed its reporting procedures for enrollment changes occurring after initial term reporting and implemented procedural changes to ensure timely updates. Anticipated Completion Date: Corrective action occurred prior to June 30, 2025. Name of Contact Person Responsible for the Corrective Action Plan: Stacy Wyeth, Registrar

View Audit 389473

Finding 1175652 (2025-005)

Material Weakness 2025

City of Syracuse, New York

NY

Special Tests & Provisions Internal Control / Segregation of Duties

The City remains committed to complying with Uniform Guidance requirements and acknowledges the importance of strengthening internal controls related to the inspection process. To support this effort, a centralized tracking system will be implemented to monitor inspection deadlines for all HOME-assi...

The City remains committed to complying with Uniform Guidance requirements and acknowledges the importance of strengthening internal controls related to the inspection process. To support this effort, a centralized tracking system will be implemented to monitor inspection deadlines for all HOME-assisted rental units. The City will also enhance its policies and procedures to clearly define staff responsibilities, inspection scheduling protocols, documentation standards, and required follow-up actions for units found to be out of compliance. Expected Completion: June 30, 2026 Responsible Contact Person: Michael Cannizzaro, Commissioner of Finance, 315-448-8323

View Audit 389472

Finding 1175646 (2025-003)

Material Weakness 2025

Durham Public Schools

NC

Subrecipient Monitoring Cash Management Material Weakness

Contact Person: Jeremy Teetor, Chief Financial Officer Corrective Action Plan: The finding resulted primarily from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely bas...

Contact Person: Jeremy Teetor, Chief Financial Officer Corrective Action Plan: The finding resulted primarily from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. The Finance department will also strive to keep key positions filled at all times and ensure that staff receives appropriate training regarding reconciliations. Proposed Completetion Date: Immediately

View Audit 389467

Finding 1175636 (2025-002)

Material Weakness 2025

Santa Barbara Community College District

CA

Student Financial Aid

The District has identified the issue and confirmed that enrollment records are now populating with the correct withdrawal dates. Moving forward, we will collaborate with Financial Aid and IT to implement a validation process. As part of this process, a sample of 20 students will be tested each repo...

The District has identified the issue and confirmed that enrollment records are now populating with the correct withdrawal dates. Moving forward, we will collaborate with Financial Aid and IT to implement a validation process. As part of this process, a sample of 20 students will be tested each reporting cycle to verify that dates reported to the National Student Clearinghouse (NSC) are accurately reflected in the National Student Loan Data System (NSLDS). To ensure continued compliance, the District will establish a new Enrollment Reporting Workgroup that will meet once per semester, following the submission of the second NSC report. This workgroup will review results of the sample testing, monitor reporting accuracy, and address any discrepancies promptly.

View Audit 389455

Finding 1175632 (2025-004)

Material Weakness 2025

National University

CA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend that the University establish procedures to ensure that FISAP is accurately presented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: National University (NU) agrees with the importanc...

Recommendation: We recommend that the University establish procedures to ensure that FISAP is accurately presented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: National University (NU) agrees with the importance of ensuring the accuracy of its data reported in the FISAP. The University will take the following steps to resolve the issue. NU identified a knowledge gap for the tuition and fees reporting required on the FISAP. Training will be conducted to review the requirements for reporting tuition and fees at the Undergraduate and Graduate levels, which are fully reconciled to the audited financial statements. In addition to the training, the University has implemented a secondary review of the calculation, which will be completed by the University controller prior to submission. Name(s) of the contact person(s) responsible for corrective action: - Robert Conlon, AVP Financial Aid Compliance - Christina Nowacki, Controller Planned completion date for corrective action plan: December 2025

View Audit 389454

Finding 1175626 (2025-003)

Material Weakness 2025

National University

CA

Student Financial Aid Allowable Costs / Cost Principles Significant Deficiency

Recommendation: We recommend that the University establish procedures to ensure that at least 7% of Federal Work Study allocation is used for community service jobs, including a reading tutor, or successfully receive a waiver. Explanation of disagreement with audit finding: There is no disagreement ...

Recommendation: We recommend that the University establish procedures to ensure that at least 7% of Federal Work Study allocation is used for community service jobs, including a reading tutor, or successfully receive a waiver. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: National University (NU) agrees with the importance of ensuring compliance with FWS community service requirements. The University implemented additional internal controls and policy changes to how it administers the FWS program and completes FISAP reporting to resolve this issue. During NU’s annual FISAP reporting process, it discovered that it had not met its FWS community service obligation. The University submitted a waiver, but it was denied. The University took immediate action to determine the cause of not meeting its FWS community service obligations. Community Partnership Management: National University previously had a partnership with Barrio Logan College Institute (BLCI) located in San Diego, CA. This partnership changed during the pandemic when all schools received a waiver for the community service requirement. In August 2024, Elyse Joiner, Director of Financial Aid Processing, again reached out to BLCI to reestablish a partnership. At that time, National was informed that the previous point of contact was no longer employed with BLCI, but the institute was still interested in partnering with National to meet the community service requirement for Federal Work Study. Ms. Joiner had several communications with BLCI to implement and finalize the setup of the reading and math tutors, with the only outstanding item related to the need for a virtual option. Unfortunately, communication between National University and BLCI ceased in April 2025 when National stopped receiving responses from BLCI to its inquiries. To establish another partnership, Ms. Joiner reached out to United Way of San Diego County to explore the possibility of establishing a reading or math tutor program with them but did not receive a response. Program Administration Change: Federal Work Study funds were budgeted to meet the University’s community service requirement; however, due to unforeseen circumstances and the efforts noted above, the University was unable to meet the 7% community service requirement. The University did have tutors available to the University community, but this did not fulfill the community service requirement. National University has since rectified this for the current aid year. The positions have been posted (R 2025 3051), and the University will have multiple FWS students at the Nest at Spectrum, offering tutoring services to both NU students and the public. The YMCA next to Spectrum will also be informed about the services to promote additional awareness within the local community. Additional opportunities are being actively explored within the Student Disability Services team and the Schools of Law & Public Service and Education. Steps taken to improve transparency and tracking: The University conducted a holistic review of the current FWS policies and procedures and has or will take the following steps: o Comprehensive training for administering the FWS program and Campus-Based Funding programs o Develop and implement an internal control plan that monitors FWS spending activity, allowing for the proactive identification of when the University should reallocate funds between campus-based programs. o Implemented quarterly calibration meetings between FWS/Operations leaders and HR to ensure its FWS program is on track to meet the FWS community service, literacy, and tutoring regulatory requirements. o Explore the expansion of community service relationships and opportunities within the Federal Work Study Program. Name(s) of the contact person(s) responsible for corrective action: - Alan Coddington, AVP Student Financial Services - Elyse Joiner, Director of Operations, Financial Aid Processing and Technical Solutions - Rob Conlon, AVP Financial Aid Compliance Planned completion date for corrective action plan: February 2026

View Audit 389454

Finding 1175625 (2025-002)

Material Weakness 2025

National University

CA

Student Financial Aid Subrecipient Monitoring Reporting

Recommendation: We recommend the University establish and implement a contingency process to ensure enrollment reporting continues during system access disruptions. This process should include monitoring NSC access status and developing alternative procedures to prevent reporting gaps, ensuring that...

Recommendation: We recommend the University establish and implement a contingency process to ensure enrollment reporting continues during system access disruptions. This process should include monitoring NSC access status and developing alternative procedures to prevent reporting gaps, ensuring that all student statuses are submitted accurately and within the required 60-day timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: National University agrees with the importance of ensuring accurate and timely enrollment reporting to NSLDS. The University has taken significant steps to improve its internal controls and compliance with enrollment reporting requirements. The University has identified a few items that have resulted in challenges to accurate and timely enrollment reporting during the audit year. National Student Clearing House (NSC) reporting: On October 18, 2024, the institution was notified by NSC that its access to process enrollment reporting on behalf of NU was revoked during July 2024, resulting in a reporting gap. The University took immediate action to restore access to NSC. Access issues were fully resolved on October 23, 2024. Additionally, NU revised its policies and implemented an internal control plan that monitors NSC activity allowing for proactive identification of future service interruptions. All 33 enrollment certification errors occurred during the disconnect noted above. The University believes its current enrollment certification processes are timely, accurate, and compliant. Timing of implemented enrollment reporting changes: During the audit period National University implemented several improvements to refine and enhance the timeliness of its enrollment reporting. NU established stronger alignment across both OPEIDs and adjusted its timelines to ensure consistent and timely submissions. As part of this effort, the University restructured its reporting schedule, so that finalized enrollment report is submitted by the 6th of each month, supporting a successful and expedited monthly transfer from NSC to NSLDS. Since implementing these revised timelines and deadlines, the University has observed significant improvements and consistency in its internal QA audit scores during the audit period (since January 2025). Four of the five late reporting instances occurred before the implementation date of the University’s enrollment reporting changes. The University believes its refined and enhanced process changes demonstrate its commitment to timely, accurate, and compliant enrollment certification processes. One of the five late reporting instances occurred after the implementation date, and that was related to the student’s status change from active, to pending graduate, to graduate, and then withdrawn. The University will evaluate its process for reporting student status changes from pending graduate, graduate, and withdrawal to ensure clear definitions and status flows are in place. The University will create and deliver focused training in this area to stress the importance of accurate enrollment reporting. In addition to the above, the University will continue to take the following steps: • Continued monitoring and refining of processes to maintain timely and accurate reporting. Including, but not limited to its monthly testing of enrollment reporting accuracy to NSLDS conducted by the quality assurance team. • Identification and timely delivery of training for areas of opportunity identified in the monthly reviews to the registrar and data operations teams. • Revise the internal changes and documentation processes to ensure clarity of policy and regulatory guidance in areas of identified risk/confusion during enrollment reporting processing. Name(s) of the contact person(s) responsible for corrective action: - Rob Conlon, AVP Financial Aid Compliance - Sarah Massey, AVP of Operations Student Support and Registrar Operations - Gabrielle Witruke, Associate Director Data Analytics Planned completion date for corrective action plan: November 2025

View Audit 389454

Finding 1175619 (2025-001)

Material Weakness 2025

National University

CA

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Recommendation: We recommend the University review the R2T4 requirements and implement adequate procedures to make sure that students that withdrew have a calculation performed. We also recommend the University to evaluate the R2T4 review process to ensure Title IV funds are returned timely. Explana...

Recommendation: We recommend the University review the R2T4 requirements and implement adequate procedures to make sure that students that withdrew have a calculation performed. We also recommend the University to evaluate the R2T4 review process to ensure Title IV funds are returned timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University agrees with the importance of ensuring that the return of Title IV funds (R2T4) calculation is performed both timely and accurately. The University has taken significant steps to improve its compliance with R2T4 requirements. These efforts have yielded improved results with the late return error rate decreasing year over year from 13% to 7%. The University will continue to monitor staffing levels and workload to ensure that staffing aligns with timeline requirements. The University’s Processing team will lead focused R2T4 training on topics related to areas of noncompliance. Additional topics will be identified throughout the year as trends are identified in the Quality Assurance Audit process. The following steps will be taken immediately to address finding 2025-001. - The Processing team will continue to conduct subject matter training monthly, prioritized as follows: o Post Withdrawal Disbursements (PWD) identification o Post Withdrawal Disbursement timeline requirements - A new weekly review will be implemented by quality assurance outside of the review completed by R2T4 leadership to test if processing specialists are accurately determining if an R2T4 is required and if a refund is needed for a withdrawn student. Results will be used to coach staff members as needed. The University’s Quality Assurance team will continue to conduct weekly R2T4 reviews to test the R2T4 calculation for accuracy, timeliness of funds returned, and verifying that all internal and external system inputs are completed correctly. Findings from the internal audits will inform ongoing training and remediation steps throughout the year. Name(s) of the contact person(s) responsible for corrective action: - Rob Conlon, AVP Financial Aid Compliance - Alan Coddington, AVP Student Financial Services - John Okel, Director of Operations, Financial Aid Processing Planned completion date for corrective action plan: January 2026

View Audit 389454

Finding 1175613 (2025-005)

Material Weakness 2025

Otero County

NM

Subrecipient Monitoring Reporting § 200.331

Views of Responsible Officials Management concurs with the finding. The Operation Stonegarden grants are managed by Broken Arrow Services, LLC, who is contracted with Otero County for this purpose. Broken Arrow Services, LLC has communicated to all sub-recipients the importance of submitting reports...

Views of Responsible Officials Management concurs with the finding. The Operation Stonegarden grants are managed by Broken Arrow Services, LLC, who is contracted with Otero County for this purpose. Broken Arrow Services, LLC has communicated to all sub-recipients the importance of submitting reports and invoices in a timely manner so that financial and performance reports can be completed and submitted to DHSEM by the required deadlines each quarter. All late submissions by sub-recipients will be tracked and follow-up efforts will be documented. Reimbursement to sub-recipients who are not in compliance will be withheld until all proper documentation and reporting has been submitted and reviewed for accuracy. Finding Resolutions Timeline: June 30, 2026 Designation Of Employee Position Responsible For Meeting This Deadline: Finance Director

View Audit 389450

Finding 1175612 (2025-004)

Material Weakness 2025

Otero County

NM

Reporting Subrecipient Monitoring Cash Management § 200.303

Views of Responsible Officials Management concurs with the finding. The Operation Stonegarden grants are managed by Broken Arrow Services, LLC, who is contracted with Otero County for this purpose. For future audits, management will refer auditors directly to Broken Arrow Services, LLC for all docum...

Views of Responsible Officials Management concurs with the finding. The Operation Stonegarden grants are managed by Broken Arrow Services, LLC, who is contracted with Otero County for this purpose. For future audits, management will refer auditors directly to Broken Arrow Services, LLC for all documentation, (other than the SEFA and general ledger reports), as they maintain the most accurate and up-todate records for all reporting, purchases, and reimbursements. Broken Arrow Services, LLC has communicated to all sub-recipients the importance of submitting reports and invoices in a timely manner so that financial and performance reports can be completed and submitted to DHSEM by the required deadlines each quarter. All late submissions by sub-recipients will be tracked and follow-up efforts will be documented. The SEFA report did not include the expenditures for sub-recipients, and this was an honest oversight that will not be omitted in the future. The Finance Department will continue to prepare the SEFA and provide general ledger reports to the auditors. Finding Resolutions Timeline: Completed. December 18, 2025 Designation Of Employee Position Responsible For Meeting This Deadline: Finance Director

View Audit 389450

Finding 1175611 (2025-002)

Material Weakness 2025

Lehigh University

PA

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

Finding 2025-002; Lehigh acknowledge that in two instances, Title IV credit balances were not refunded within the required 14-day timeframe. The two exceptions identified were isolated in nature and attributable to unique circumstances rather than systemic process failure. In the first instance, the...

Finding 2025-002; Lehigh acknowledge that in two instances, Title IV credit balances were not refunded within the required 14-day timeframe. The two exceptions identified were isolated in nature and attributable to unique circumstances rather than systemic process failure. In the first instance, the student was enrolled in the summer term and their summer Pell Grant was not processed until October. As a result, the Title IV credit balance was created well after the end of the summer payment period, outside of our typical refund monitoring cycle for that term. In the second instance, the credit balance was identified within the 14-day requirement. However, the student had not enrolled in direct deposit through the eBill system. Lehigh contacted the student to obtain payment instructions. When no banking information was provided to Lehigh, a paper check had to be issued, which extended the disbursement timeline beyond the 14-day period. While these situations were atypical, we recognize the importance of ensuring timely disbursement regardless of individual circumstances. To strengthen controls, we continue to prioritize Title IV credit balance refunds over refunds resulting from institutional aid or other funding sources to ensure compliance with federal timelines. Although we continue our institutional practice of holding refunds until after the 10th day of class to account for schedule adjustments and enrollment changes, we will begin generating and reviewing credit balance reports earlier in the cycle to allow sufficient processing time. We will implement automated reporting to identify credit balances that occur after the end of an academic period. These reports will be sent to a shared bursar office email account rather than an individual staff member. This will ensure visibility and actionability even during staff absences, turnover, or non-workdays. Responsibility for monitoring and processing Title IV credit balances will be formally documented. Multiple staff members will be trained in the procedures to ensure appropriate backup coverage during employee absences, leave, or staffing transitions. Management will periodically review refund timelines to confirm adherence to procedures and verify that credit balances are disbursed within regulatory timeframes. We believe these corrective actions address the audit recommendation and will ensure timely and consistent processing of Title IV credit balance disbursements regardless of staffing availability.Name of contact person: Jennifer Mertz is the Assistant Vice Provost of Financial Services and Director of Financial Aid. Completion date: All of the control strengthening mechanisms and documentation will be complete by June 30, 2026.

View Audit 389449

Finding 1175608 (2025-004)

Material Weakness 2025

La Salle University

PA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.032, 84.033, 84.063 Recommendation: We recommend the University review its policies and procedures related to outstanding Title IV checks to ensure they are being returned to the Department of Education after being outstanding ...

Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.032, 84.033, 84.063 Recommendation: We recommend the University review its policies and procedures related to outstanding Title IV checks to ensure they are being returned to the Department of Education after being outstanding more than 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: La Salle University AVP/Controller and AVP/Student Financial Service have reviewed the finding related to the escheatment of Title IV student refunds and have implemented a formal step-by-step process and policy to ensure compliance going forward. The updated procedure outlines clear responsibilities, required timelines, and documentation standards for processing unclaimed refunds and escheating funds in accordance with federal and state regulations. Staff have been informed of the new process and will follow the documented policy moving forward. Name(s) of the contact person(s) responsible for corrective action: AVP/Controller, Viviana Yang and AVP/Student Financial Service, Michele McDevitt. Planned completion date for corrective action plan: March 31,2026

View Audit 389443

Finding 1175607 (2025-003)

Material Weakness 2025

La Salle University

PA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies to ensure correct dates are being used in the calculation and that it is reviewed for accuracy. Explanation of disagreement with audit...

Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies to ensure correct dates are being used in the calculation and that it is reviewed for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Selected semester-related values in our Student Information System (BANNER) will be reviewed for compliance with the official, stated values in the school’s academic calendar. Adjusting for Housing-related dates or potential extensions due to possible delays caused by uncontrollable events will not be included. Name(s) of the contact person(s) responsible for corrective action: Gerard Donahue, Registrar Planned completion date for corrective action plan: Corrected as of Summer 2026 (Fall 2025 and Spring 2026 are already in process as of this writing)

View Audit 389443

Finding 1175606 (2025-002)

Material Weakness 2025

La Salle University

PA

Reporting Student Financial Aid Material Weakness

Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its policies and procedures around reporting student status changes to the NSLDS to ensure that all relevant information is being captured and reported timely in accordan...

Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its policies and procedures around reporting student status changes to the NSLDS to ensure that all relevant information is being captured and reported timely in accordance with applicable regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: La Salle contractually relies on the National Student Clearinghouse (NSC) to conduct its enrollment reporting to NSLDS. While there has been closer adherence to the overall transmission schedule established with the NSC, and this covers enrollment reporting for the vast majority of our registered students, such was not always the case in prior semesters, and selected exceptional registration transactions are not directly reported when they actually occur, resulting in delays, until the next regularly scheduled transmission. Going forward, upon encountering these exceptional transactions, we will take steps to ensure reporting of individual enrollments to the NSC within 1-2 business days following the transaction’s occurrence. Name(s) of the contact person(s) responsible for corrective action: Gerard Donahue, Registrar Planned completion date for corrective action plan: Corrected as of Spring 2026 (Fall 2025 is already complete as of this writing)

View Audit 389443

Corrective Action Plans

Filters