Corrective Action Plans

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Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 7AZ300AZ3, 6AZ300400, 7AZ310AZ1 Contact Person: Dominick Ruth, Director of Finance Anticipated Completion Date: July 1, 2025 Planned Corrective Action: Creighton School District #14 wi...
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 7AZ300AZ3, 6AZ300400, 7AZ310AZ1 Contact Person: Dominick Ruth, Director of Finance Anticipated Completion Date: July 1, 2025 Planned Corrective Action: Creighton School District #14 will review vendor awards in Visions and ensure that expired awards or awards that do not qualify as a competitive procurement awards are removed from the ERP system. In FY26, and in future the fiscal years, the District will obtain three written quotes for the Nutrition department's purchases from the associated vendor.
Claremont Graduate University Corrective Action Plan For the Fiscal Year Ended June 30, 2025 U.S. Department of Education FINDING 2025-001 – Special Tests and Provisions-Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Condition – During the audit fieldwork, a sample ...
Claremont Graduate University Corrective Action Plan For the Fiscal Year Ended June 30, 2025 U.S. Department of Education FINDING 2025-001 – Special Tests and Provisions-Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Condition – During the audit fieldwork, a sample of 20 federal aid recipient students were selected by auditors from system generated reports of students who graduated, reported a physical address change, withdrew, or dropped during the 2024-2025 academic year. The enrollment information and withdrawal, address change, or graduation date per the University’s records was compared to the information reported to the National Student Loan Data System (NSLDS) in order to determine if status changes were reported within the required timeframes. Of the 20 students who had a change in address, graduated, or withdrew, there were four student files with errors. There was one student file that had incorrect enrollment status reported and not reported within the required timeframe. A second student file was reported under the incorrect enrollment status but within the appropriate time requirement. Lastly, two additional student files were not reported within the required timeframe. Explanation of Deficiency On June 20, 2025, the Degree Verify transmission to the National Student Clearinghouse (NSC) failed. Additionally, an error was identified that caused all international student records to be rejected. In order to correct the omission of international students, the monthly transmission was temporarily stopped until the issue could be resolved. This process took longer than anticipated. While degree records were being manually updated in NSC, staff were not aware that the enrollment records also needed to be separately updated. The Degree Verify file had been configured with a flag that should have automatically updated enrollment records upon submission, but this was not recognized at the time. As a result, a sample of student files reviewed contained reporting errors related to incorrect enrollment statuses or reporting delays. These issues would have been avoided if regularly scheduled reports had been submitted to NSC without interruption. Corrective Action Plan To address these deficiencies and prevent recurrence, the following corrective measures have been implemented: 1. Resumption of Scheduled Transmissions – The Office of Information Technology has corrected the Degree Verify file rejection issue. Monthly transmissions of Degree Verify reports will resume beginning September 20, 2025. 2. Enhanced Enrollment Reporting Schedule – Enrollment reporting has been rescheduled to occur every three weeks throughout each term, ensuring that enrollment status changes are reported to NSC and NSLDS within required timeframes. 3. Manual Record Reconciliation – A comprehensive review of late degree conferrals has been completed. All enrollment records have been manually updated in NSC to align with the corresponding degree records. 4. Staff Training and Awareness – The Registrar’s Office staff have been trained on the functional differences between degree reporting and enrollment reporting. Emphasis was placed on the need to verify that enrollment records are updated when degree records are manually corrected. 5. Monitoring and Quality Control – A reconciliation process has been established between the Registrar’s Office and OIT to confirm the successful transmission and acceptance of NSC files. Reports of any rejected records will be reviewed within five business days and promptly corrected. Contact Person Responsible: Vannessa Alvarado, Registrar 909-621-8285 Anticipated/Projected Completion Date: Manual corrections completed on September 3, 2025. Automated processes to projected September 20, 2025.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made depos...
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made deposits into the reserve for replacement to make up the shortfall. Management will work with the Bank and HUD to ensure the accuracy of the “true-up” payments made.
Finding 2025 – 003 - Reporting (Significant Deficiency and Noncompliance) Management’s Response: Management concurs with the above finding, and the Fiscal Service Office will implement corrective action before September 2026. Management acknowledges the process gap as indicated and noted in the abov...
Finding 2025 – 003 - Reporting (Significant Deficiency and Noncompliance) Management’s Response: Management concurs with the above finding, and the Fiscal Service Office will implement corrective action before September 2026. Management acknowledges the process gap as indicated and noted in the above findings. To enhance the effectiveness of internal controls and ensure that all Title III reports are accurate, properly reviewed, and approved prior to submission, the Fiscal Service office will require management to review and sign off as confirmation of approval prior to submission.
Finding 2025 – 002- Allowable Costs & Period of Performance (Significant Deficiency and Noncompliance) Management’s Response: Management concurs with the above finding, and the Fiscal Service Office will implement corrective action before September 2026. Management acknowledges the process gap as in...
Finding 2025 – 002- Allowable Costs & Period of Performance (Significant Deficiency and Noncompliance) Management’s Response: Management concurs with the above finding, and the Fiscal Service Office will implement corrective action before September 2026. Management acknowledges the process gap as indicated and noted in the above findings. To strengthen policies and procedures surrounding grant disbursements and ensure expenses are properly approved and allowable under the specific grant budget, the Fiscal Service Office along with the Human Resources Department will implement a process to properly document, review, and approve all allowable grant pay rates and salaries.
Finding 2025 – 004 - Special Tests and Provisions- Enrollment Reporting (Significant Deficiency and Noncompliance) Management’s Response: Management concurs with the above finding, and the Fiscal Service Office will implement corrective action before September 2026. Management acknowledges the proce...
Finding 2025 – 004 - Special Tests and Provisions- Enrollment Reporting (Significant Deficiency and Noncompliance) Management’s Response: Management concurs with the above finding, and the Fiscal Service Office will implement corrective action before September 2026. Management acknowledges the process gap as indicated and noted in the above findings. The Director of Admissions and Records has stated that students who have a student attribute in Banner of INTL will no longer be excluded from the National Student Clearinghouse enrollment reporting upload so as to prevent any reporting issues due to human error when processing admissions applications.
Response and Corrective Action Plan: The District will annually prepare the indirect cost charged to the program based on the actual fiscal year trial balance and the federal government MTDC requirements. The calculation process will implement a procedure to consider other adjustments necessary to b...
Response and Corrective Action Plan: The District will annually prepare the indirect cost charged to the program based on the actual fiscal year trial balance and the federal government MTDC requirements. The calculation process will implement a procedure to consider other adjustments necessary to be in compliance. The District will provide an estimate to the Board each June to ensure proper approval of fund transfers.
SA2025-001 - Suspension or Debarment Verification (Significant Deficiency)The City has already taken steps to formalize compliance by incorporating suspension and debarment requirements into the Grant Administration Policy approved by Council on June 18, 2025. Moving forward, the City will strengthe...
SA2025-001 - Suspension or Debarment Verification (Significant Deficiency)The City has already taken steps to formalize compliance by incorporating suspension and debarment requirements into the Grant Administration Policy approved by Council on June 18, 2025. Moving forward, the City will strengthen internal controls by updating its standard procurement contract templates to include suspension and debarment language. Additionally, City staff will perform and document a verification check prior to entering into any covered transaction.
Finding 2025-001 – Allowable Costs (Significant Deficiency and Noncompliance) Information on the Federal Program: U.S. Department of Education, Trio Cluster Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfederal entities are also requ...
Finding 2025-001 – Allowable Costs (Significant Deficiency and Noncompliance) Information on the Federal Program: U.S. Department of Education, Trio Cluster Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfederal entities are also required to establish controls over the disbursement process to ensure compliance with allowable cost requirements. Condition: We selected a sample of 25 payroll charges, containing 57 employees. Of those 57, 2 exceptions were noted related to documentation. One employee’s last letter of appointment indicated the position was 100% Trio; however, the employee was allocated only at 50%, and their new allocation was not documented in a new letter of appointment. And one employee had more than one position but the additional position added letter of appointment or change of status was not provided. Management’s Response: The 2 exceptions noted were documented and had appropriate approvals. However, the form of the documentation was not the form listed in the local procedures. Bevill State will ensure that the form of the documentation and the local procedures are consistent moving forward. Anticipated Completion Date: February 28, 2026
Significant Deficiency in Internal Control over Financial Reporting Recommendation: We recommend the District continue to improve its processes and procedures surrounding reporting of claims meal summaries. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Significant Deficiency in Internal Control over Financial Reporting Recommendation: We recommend the District continue to improve its processes and procedures surrounding reporting of claims meal summaries. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to develop processes and procedures to ensure reports tie to claims summaries for meal counts. Name of the contact person responsible for corrective action: Shari Thompson Planned completion date for corrective action plan: June 30, 2026.
The District will implement a monthly reconciliation process to compare production reports prepared by cafeteria staff to the meal system report used for reimbursement claims. Any discrepancies will be reviewed and resolved prior to claim submission, and the review will be documented to ensure consi...
The District will implement a monthly reconciliation process to compare production reports prepared by cafeteria staff to the meal system report used for reimbursement claims. Any discrepancies will be reviewed and resolved prior to claim submission, and the review will be documented to ensure consistent and accurate internal reporting.
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See table on page 48.
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See table on page 47.
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See table on page 33.
Finding 1169441 (2025-001)
Material Weakness 2025
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See table on page 34.
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See table on page 32.
I. Corrective Action Plan Finding 2025-001 Significant Deficiency in Internal Control Over Compliance for Reporting Corrective Action Plan: To prevent this issue going forward, Midland College will incorporate the following steps into the new award year checklist: • Confirm that no data has been inc...
I. Corrective Action Plan Finding 2025-001 Significant Deficiency in Internal Control Over Compliance for Reporting Corrective Action Plan: To prevent this issue going forward, Midland College will incorporate the following steps into the new award year checklist: • Confirm that no data has been incorrectly carried over from the previous year. • Cross-check student budgets to ensure alignment with COD. Additionally, at the start, midpoint, and end of each semester, Midland College will conduct internal reviews of a random sample of students to verify the accuracy of the Cost of Attendance (COA). Responsible Officials: Tiffany Adair, Midland College Director of Financial Aid – Compliance and Reporting Anticipated Date of Completion: December 2025
Sliding Scale Assessment Billing Planned Corrective Action: Clinic management will implement additional checks and balances to ensure that Sliding Fee Application Forms and written income verification documentation are included in patients’ records and agree to the sliding fee level maintained in th...
Sliding Scale Assessment Billing Planned Corrective Action: Clinic management will implement additional checks and balances to ensure that Sliding Fee Application Forms and written income verification documentation are included in patients’ records and agree to the sliding fee level maintained in the electronic health records system. The Revenue Cycle Manager will increase the level of monitoring of required documentation of sliding fee levels used in billing patient charges. Person Responsible for Corrective Action Plan: Steonée Laskey, Chief Operations Officer Anticipated Date of Completion: January 31, 2026
2025-001: Missing Exit Counseling Documentation Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, 84.379 Grant Period – Year Ended June 30, 2025 Condition Found Condition/Context: During our student file testing, we noted two students out of forty did not have d...
2025-001: Missing Exit Counseling Documentation Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, 84.379 Grant Period – Year Ended June 30, 2025 Condition Found Condition/Context: During our student file testing, we noted two students out of forty did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be an instance of noncompliance with the Eligibility Compliance Requirement. Corrective Action Plan Concordia has created new reporting and updated its Exit Counseling policy to put any students without concurrent semester enrollment, excluding traditional undergraduates who are not required to take summer, into "EXIT". Responsible person for corrective action plan: Kevin Sheridan Implementation Date of Corrective Action Plan: December 11, 2025
2025-002 Significant Deficiency: Working During Scheduled Class Time (U.S. Department of Education - Federal Work Study Program, ALN #84.033) The University noted that multiple students appear to have been paid for Federal Work Study hours logged and submitted for time the student was scheduled to b...
2025-002 Significant Deficiency: Working During Scheduled Class Time (U.S. Department of Education - Federal Work Study Program, ALN #84.033) The University noted that multiple students appear to have been paid for Federal Work Study hours logged and submitted for time the student was scheduled to be in class without verification of a reasonable exemption. Management Response Management concurs with the auditor’s finding. Due to incomplete documentation of reasonable exemptions, students were paid Federal Work Study funds for time worked during regularly scheduled class meeting times. Responsible Person(s) Alex Campbell, Director of Financial Aid, and Bobbi Farris, Manager for Student Employment, are the responsible parties for the corrective action. Corrective Action Plan Upon identifying deficiencies related to the lack of documentation for allowable exemptions, the University immediately communicated with all Student Employment Supervisors regarding permitted exemptions and required documentation for students to work during scheduled class times. These requirements and exemptions are reviewed and agreed upon during the annual Student Employment Supervisor Trainings, which occur prior to job postings. Students are notified of the documentation required to be exempt and eligible to work during a scheduled class time during the onboarding process. In collaboration with Information Technology and third-party consultants, the Student Employment Office is enhancing reporting functions to ensure accurate identification of students with conflicting work and class times and to flag any conflicting entries for review and resolution prior to approval. These reports will be reviewed each pay period to ensure accurate documentation is obtained for any conflicting times flagged. While these fields are being implemented, regulations related to working during scheduled class times have been reinforced with both students and supervisors. Beginning with the Spring 2026 term, the University will implement a new policy prohibiting students participating in the Federal Work Study Program from working during scheduled class times, regardless of any met exemptions. All Student Employment Supervisors will be notified of this updated policy by the end of the Fall 2025 term. Training will continue on an annual basis to ensure proper procedures are followed by Student Employment Supervisors and students participating in the Federal Work Study Program. The Director of Financial Aid and Manager for Student Employment will review student time records each pay period to ensure full compliance with these policies. Expected Completion Date This corrective action plan was implemented in September 2025, during the Fall 2025 term. Final implementation will occur at the start of the Spring 2026 term.
2025-001 Significant Deficiency: Awards in Excess of Aggregate Limits (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) The University awarded and disbursed Federal Direct Loans beyond aggregate limits. Management Response Management concurs with the auditors’ finding....
2025-001 Significant Deficiency: Awards in Excess of Aggregate Limits (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) The University awarded and disbursed Federal Direct Loans beyond aggregate limits. Management Response Management concurs with the auditors’ finding. Due to delays and changes in the National Student Loan Data System (NSLDS) post-screening process for the 2024–25 award year, Federal Direct Loans were inadvertently awarded and disbursed to students who had previously exceeded Federal Direct Loan aggregate limits. Responsible Person(s) Alex Campbell, Director of Financial Aid, and Kaitrin Parrett, Assistant Director of Financial Aid, are designated as the individuals responsible for implementing the corrective action. Corrective Action Plan Upon identifying deficiencies in loan aggregate reporting and over-award status, the Financial Aid Office initiated communication with the identified students to inform them of their overaward status and the process for resolving inadvertent overborrowing. In collaboration with software engineers, the Financial Aid Office is developing updated reporting to ensure proper identification of students who are ineligible due to meeting or exceeding aggregate limits set by the U.S. Department of Education. The Financial Aid Office tested and reviewed NSLDS post-screen data and student loan aggregates prior to the disbursement of Fall 2025 Federal Direct Loans to ensure students were not awarded or disbursed aid for which they were ineligible. Reviews of NSLDS post-screen data confirm that the Student Information System (SIS) accurately identifies student aggregate borrowing flags. The Financial Aid Office is also monitoring designated mailboxes to ensure any additional NSLDS post-screen data is reviewed and aggregate limits on student accounts are updated accordingly. All financial aid staff involved in awarding federal loans completed additional training on NSLDS review requirements, aggregate limit monitoring, and reaffirmation procedures prior to Fall 2025 disbursements. Training will continue on a quarterly basis to ensure proper procedures are followed by Financial Aid staff. Compliance reviews will be conducted on a semester basis to ensure that Title IV aid is not awarded to students in excess of their annual or aggregate limits. The Director and Assistant Director of Financial Aid will review aggregate limit reports monthly as part of the University’s internal operational calendar. Expected Completion Date This corrective action plan was implemented in September 2025, prior to Fall 2025 aid disbursements, which began on September 12, 2025.
Contact – Haresh Vayal, Chief Financial Officer and Lisa Choate, President and CEO Telephone Number – (202)-833-7522 Completion Date – March 31, 2026 2025-001 – Internal Control Over Compliance and Compliance with Cash Management Corrective Action Plan: The Organization’s Federal awards are primaril...
Contact – Haresh Vayal, Chief Financial Officer and Lisa Choate, President and CEO Telephone Number – (202)-833-7522 Completion Date – March 31, 2026 2025-001 – Internal Control Over Compliance and Compliance with Cash Management Corrective Action Plan: The Organization’s Federal awards are primarily administered on a reimbursement basis. During fiscal year 2025, however, the Organization was required to draw advances on certain Federal awards due to changes in the political landscape. The guidance identified by the auditors is acknowledged. Management will implement a formal process to track Federal cash advances and monitor interest earned on those advances in compliance with Federal cash management requirements. Additionally, the Organization will calculate interest earned on Federal advances received during fiscal year 2025 and remit any interest earned in excess of $500 to the Federal government within 12 months of the date the advances were received. The Finance Department will monitor Federal cash advances on a monthly basis to ensure compliance with Federal cash management requirements. This monitoring will include reviewing the timing of advances, tracking interest earned on Federal funds, and reconciling advance balances to allowable expenditures. Interest calculations will be reviewed by management, and any interest earned in excess of $500 will be remitted to the Federal government within the required timeframe. Management will periodically review the process to ensure controls are operating effectively and make adjustments as necessary. Management believes these corrective actions will ensure compliance with applicable Federal cash management regulations going forward.
Individuals Responsible for Corrective Action Plan: •Collections Coordinator •Director of Student Accounts Condition: Life University transitioned from UAS services to ECSI. In the transition of that service provides, documentation that was to be maintained to remain compliant with the Federal Perki...
Individuals Responsible for Corrective Action Plan: •Collections Coordinator •Director of Student Accounts Condition: Life University transitioned from UAS services to ECSI. In the transition of that service provides, documentation that was to be maintained to remain compliant with the Federal Perkins loan program was lost. The university has attempted on numerous occasions to assign the defaulted loans using alternative documentation to verify the debt. All attempts have been denied. The university has now been in practice with the current corrective action plan to address the deficiencies in documentation and reestablish the validity of the debt. Management’s Corrective Action Plan: Life University has implemented and continues to maintain the following corrective measures to ensure ongoing compliance: 1.Borrower Contact and Notification Life University has initiated and continues to conduct proactive outreach to borrowersrequiring an updated or newly established MPN (Master Promissory Note) or equivalentdocumentation. Communication is conducted through multiple channels, including: •Phone •Email 2.Clear Documentation Instructions The University will continue to issue formal notices to affected borrowers outlining therequirement for a new MPN or equivalent documentation. Each notice includes step-by-stepinstructions for completion, a clear explanation of the purpose and importance of the MPN,and information regarding its impact on the borrower’s outstanding loan balance. 3.Reassignment of Collection Rights Upon borrower completion of the required documentation, Life University has coordinatedwith ECSI to reassign the University’s right to collect on any remaining balances. This processcontinues to be applied as additional borrowers complete their documentation. 4.Documentation Review and Verification The University has established and continues to follow a review process to verify that eachnew MPN is complete, accurate, and properly executed. This ensures that borrower consentis valid and that all collection rights are appropriately reassigned. 5.Financial Record Updates Life University has updated and continues to maintain accurate financial records reflectingthe new MPNs and reassigned collection rights. Outstanding amounts, repayment schedules,and related data are verified and recorded to ensure consistency with federal andinstitutional requirements. 6.Ongoing Communication and Monitoring The University continues to monitor borrower compliance and maintain communicationthroughout the process. Regular follow-ups and reminders are sent as needed to ensuretimely completion and documentation integrity. At the conclusion of a 12 month outreach,students who have not verified their debt to come within compliance will be written off. Anticipated Completion Date: ongoing
Individuals Responsible for Corrective Action Plan: •Director of Student Accounts •IT Systems Administrator •CIO •Senior Director of Student Administration and Compliance Cause: The notification for this student was not generated due to timing and process gaps associated with the data security incid...
Individuals Responsible for Corrective Action Plan: •Director of Student Accounts •IT Systems Administrator •CIO •Senior Director of Student Administration and Compliance Cause: The notification for this student was not generated due to timing and process gaps associated with the data security incident that occurred on July 30, 2024. The disbursement posted on Thursday, July 25, one day after the automated report selection window closed. As the team worked to assess the impact of the security incident, this process was not reviewed and this record fell outside of the reporting cycle and was not manually identified for notification. Management’s Corrective Action Plan: Incident Response and Process Impact Assessment: •Develop a standard protocol for identifying and reviewing business processes that may beimpacted during or after a data security event. •Document any suspended or delayed processes during an incident and report to IT andfollow-up. •Conduct a post-incident reconciliation of all financial aid transactions (disbursements,notifications, adjustments) to ensure completeness and compliance. •Collaborate with IT to include critical Student Account processes in the business continuityand recovery plan, ensuring prioritized restoration after any system outage or data event. Anticipated Completion Date: 2/9/2026
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