Corrective Action Plans

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SIGNIFICANT DEFICIENCY 2025-001 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Return to Title IV Condition Of the 37 students tested for Return to Title IV procedures, 2 were determined to have had errors in their calculation. Recommendat...
SIGNIFICANT DEFICIENCY 2025-001 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Return to Title IV Condition Of the 37 students tested for Return to Title IV procedures, 2 were determined to have had errors in their calculation. Recommendation We recommend that the College review and update its policies to ensure that accurate Return to Title IV calculations are completed. Comments on the Finding For the issue with an institutional charge incorrectly considered in the R2T4 calculation, this was due to a Federal Direct Parent PLUS Loan that was processed and a refund to the parent. Only seven of these loans were processed in the aid year of 2024-25, and there were no other R2T4 situations that involved a Federal Direct Parent PLUS Loan. The refund to the parent was shown at the top of the Banner form while student refunds show at the bottom of the Banner form. Due to the rarity of these loans being included in the calculation and the variation of where this charge is shown in Banner, this was missed. Barton personnel are now aware of where to look for this in these very rare cases. For the situation where the incorrect starting date was identified, there was human error when that was entered. Barton does have a quality assurance process to double check all dates on the Banner withdrawal form, and the R2T4 calculation spreadsheet, however, this review will now extend to checking the enrollment dates in a second Banner form. Action Taken Since the 2024-25 aid year was still open, both instances were corrected. Barton’s Director of Financial Aid has made all personnel aware of the issues and has revised the quality assurance review to watch for these issues.
The Institution has reviewed the details of the finding and determined the error to be due to human error and the responsibility of the Institution. Subsequent to the audit, the Institution refunded $350 in 2023-2024 Federal Pell Grant program funds on behalf of student #20 (VR). In addition the Ins...
The Institution has reviewed the details of the finding and determined the error to be due to human error and the responsibility of the Institution. Subsequent to the audit, the Institution refunded $350 in 2023-2024 Federal Pell Grant program funds on behalf of student #20 (VR). In addition the Institution refunded $419 in 2024-2025 Federal Pell Grant program funds on behalf of student #2 (EL). These two students over-award was due to a schedule or grade change that took place after the start of student’s term or payment period. The Institution will implement reporting from our SIS to monitor schedule or grade changes that take place after the start of a student’s term or payment period.
Finding #2025-001 – Internal Control Over Compliance - Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 15, 2025 Corrective Action Plan: Effective immediately, the Organiz...
Finding #2025-001 – Internal Control Over Compliance - Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 15, 2025 Corrective Action Plan: Effective immediately, the Organization will strictly enforce its policy for supervisory review and approval of employees’ time sheets and invoices. To ensure compliance with this policy, the Organization will conduct random checks of time sheets and invoices every pay period to verify that supervisory approval is performed. Appropriate disciplinary action will be implemented for non-compliance.
Finding 1165234 (2025-004)
Material Weakness 2025
2025-004: Lack of Controls over Reporting Issue: Program reports were submitted without a documented supervisory review to ensure accuracy, completeness, and compliance with reporting requirements. Corrective Actions: 1. Establish a standardized finance report review procedure for all program report...
2025-004: Lack of Controls over Reporting Issue: Program reports were submitted without a documented supervisory review to ensure accuracy, completeness, and compliance with reporting requirements. Corrective Actions: 1. Establish a standardized finance report review procedure for all program reports, including a required supervisory review before submission. 2. Implement a review checklist that includes verification of data sources, accuracy of totals, reconciliation of reported information, and confirmation that all reporting elements required by the funding agency are included. 3. Require documented evidence of review, such as supervisor signatures or electronic approval recorded in the reporting system. 4. Train all reporting and supervisory staff on the new procedures, expectations, and documentation requirements. Responsible Personnel: Grant Accountants, CFO, Program Managers Timeline: Procedures will be finalized within 10 days. Staff training will occur within 30 days. The new review process will be fully implemented by the next reporting cycle for reports due for Q2. Monitoring: Compliance will conduct quarterly spot checks to confirm adherence to the new review procedures and report results to leadership.
Finding 1165233 (2025-003)
Material Weakness 2025
2025-003: Inaccurate Eligibility Classification and System Entry Issue: Eligibility classifications in CACFP were entered incorrectly due to manual processes and inconsistent verification. In some cases, the eligibility category recorded in the system did not match the approved paper application. Do...
2025-003: Inaccurate Eligibility Classification and System Entry Issue: Eligibility classifications in CACFP were entered incorrectly due to manual processes and inconsistent verification. In some cases, the eligibility category recorded in the system did not match the approved paper application. Documentation of income verification and classification checks was incomplete or not retained. Corrective Actions: Porter-Leath will strengthen controls over eligibility determination by requiring a complete review of all eligibility documents before system entry. 1. Applications will first be checked by administrative or Family Services staff to verify household size, income documentation, and appropriate eligibility category. 2. Site Managers will review the classification for accuracy and ensure the approved determination is entered consistently into ChildPlus or ProCare. 3. A final review by the Preschool Coordinator will confirm that the eligibility classification on the application matches the classification stored in the system prior to claim submission. 4. A reconciliation step will be built into the monthly workflow so discrepancies between documentation and system data are identified and corrected promptly. Responsible Personnel: Family Services Liaisons, Site Administrative Staff, Site Managers, Preschool Coordinator, CACFP Coordinator Timeline: Revised procedures implemented within 15 days; staff training completed within 30 days. Monitoring: Periodic quarterly reviews of at least 25 percent of eligibility files will be conducted to confirm proper classification and system accuracy, with results reported to management.
Finding 1165232 (2025-002)
Material Weakness 2025
2025-002: Eligibility Determination Not in Place or Consistently Applied Across all Programs Issue: Eligibility documentation for TANF-funded services was incomplete, inconsistently applied, or missing required verification of residency, citizenship, income, resources, or other eligibility factors. ...
2025-002: Eligibility Determination Not in Place or Consistently Applied Across all Programs Issue: Eligibility documentation for TANF-funded services was incomplete, inconsistently applied, or missing required verification of residency, citizenship, income, resources, or other eligibility factors. Documentation was not always collected, reviewed, or signed before services were provided, and eligibility determinations were not supported by a uniform process. Corrective Actions: Porter-Leath will implement a standardized eligibility checklist that incorporates all TANF eligibility requirements, including verification of residency, identity, citizenship, household composition, income, resources, and work participation when applicable. 1. Staff must complete the checklist and compile all supporting documents before any TANF-funded benefits are provided. 2. When allowed under governing regulations, the Organization will also accept and retain documented eligibility determinations from other qualified programs, including SNAP, TANF acceptance letters or other qualifying documentation to determine eligibility, as part of the verification packet. 3. Each eligibility packet will require supervisory review and signature confirming that all required elements are present, accurate, and complete prior to approving eligibility. 4. The final approved packet will be maintained in accordance with DHS documentation and retention requirements. Responsible Personnel: Program Managers, Family Services Staff, Supervisors Timeline: Checklist finalized within 10 days; training within 30 days; full training and implementation immediately thereafter. Monitoring: Quarterly file reviews will confirm that eligibility checklists are correctly completed, include required documentation or accepted verification from other programs when applicable, and contain supervisory approval.
Finding 1165231 (2025-001)
Material Weakness 2025
2025-001: Meal Count Forms Not Reconciled to Claim for Reimbursement Issue: Daily and monthly meal count forms were not reconciled to the claim for reimbursement, and in several instances meals claimed exceeded participant attendance. Supervisory review was not documented, and meal count reconciliat...
2025-001: Meal Count Forms Not Reconciled to Claim for Reimbursement Issue: Daily and monthly meal count forms were not reconciled to the claim for reimbursement, and in several instances meals claimed exceeded participant attendance. Supervisory review was not documented, and meal count reconciliation occurred through manual processes that increased the likelihood of error. Corrective Actions: Porter-Leath will implement a unified reconciliation process for CACFP meal counts that requires attendance, point-of-service meal counts, and delivery counts to be reviewed together before the monthly claim is submitted. 1. Site Managers will verify that meals served never exceed daily attendance and that all claims agree to supporting census and meal documentation. 2. The Food Service Lead will prepare the monthly claim only after attendance data from ChildPlus or ProCare and meal count forms are validated and matched. 3. A supervisory review will be required at each site and documented prior to submission to CACFP leadership. 4. The CACFP Coordinator will conduct a final reconciliation to confirm accuracy and resolve discrepancies before Finance processes the claim. Responsible Personnel: CACFP Coordinator, Site Managers, Food Service Lead, Health, Disabilities & Nutrition Manager Timeline: Procedures finalized within 10 days; staff trained within 30 days; full implementation with the next monthly claim cycle after training is complete. Monitoring: Quarterly monitoring will verify adherence to reconciliation and review requirements, including documented supervisory approval.
Finding 2025-001 – Significant Deficiency – Internal Control over Distributions to Owners Compliance Status: Completed. Planned Corrective Action: CommCare Corporation will return the $20,989 distribution to CommCare St. Tammany. CommCare St. Tammany will deposit this amount into a residual receipts...
Finding 2025-001 – Significant Deficiency – Internal Control over Distributions to Owners Compliance Status: Completed. Planned Corrective Action: CommCare Corporation will return the $20,989 distribution to CommCare St. Tammany. CommCare St. Tammany will deposit this amount into a residual receipts account within the required 90 days after year-end. Management will review the HUD Regulatory Agreement to understand the Program compliance requirements and prevent future noncompliance. Person(s) Responsible: Alec Lundberg, CFO Estimated Completion Date: August 18, 2025
Finding Summary: Truckee Meadows Water Authority did not report a federal financial assistance expenditure in the correct period. Corrective Action Plan: Truckee Meadows Water Authority has updated its internal controls to better ensure federal financial assistance expenditures are reported in the c...
Finding Summary: Truckee Meadows Water Authority did not report a federal financial assistance expenditure in the correct period. Corrective Action Plan: Truckee Meadows Water Authority has updated its internal controls to better ensure federal financial assistance expenditures are reported in the correct period going forward. Responsible Individuals: Sophia Cardinal, Financial Controller Matt Bowman, Chief Financial Officer Completion Date: December 2025
Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend that management assign a designated individual to ensure rent reasonableness, income verification, and recertifications are completed accurately and on time, in accordance with HUD guidelines and the Aut...
Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend that management assign a designated individual to ensure rent reasonableness, income verification, and recertifications are completed accurately and on time, in accordance with HUD guidelines and the Authority's administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Director of HCV Program Administration and Ass istant Director of HCV Program Administration will be in charge of reviewing all Rent Reasonableness. Name(s) of the contact person(s) responsible for corrective action: Teresa J. Gonzalez, and Darrell Mciver. Planned completion date for corrective action plan: Effective immediately.
Recommendation: We recommend Mitchell Hamline School of Law review its reporting procedures to ensure the students' statuses are timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respo...
Recommendation: We recommend Mitchell Hamline School of Law review its reporting procedures to ensure the students' statuses are timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Starting in January 2026, the Registrar’s Office will be performing the monthly reporting. In preparation for this change in responsibilities, Student Financial Aid has provided training to multiple individuals in the Registrar’s Office along with detailed documented procedures. Student Financial Aid and the Registrar’s Office will coordinate responses/requests from NSLDS. Name(s) of the contact person(s) responsible for corrective action: Sheila Tolley, Executive Registrar and Nick Anderson, Director of Financial Aid Planned completion date for corrective action plan: Spring Semester 2026
Finding 2025-003 Condition Of the sample of 25 disbursements, seven students tested did not receive proper notification of the student's right, or the parent's right to cancel any portion of the loans to be distributed. The sample was not a statistically valid sample. Corrective Action Plan To addre...
Finding 2025-003 Condition Of the sample of 25 disbursements, seven students tested did not receive proper notification of the student's right, or the parent's right to cancel any portion of the loans to be distributed. The sample was not a statistically valid sample. Corrective Action Plan To address this issue, the ERP notification process has been updated to ensure students receive clear and compliant communications regarding Direct Loan disbursements. Name(s) of Contact Person(s) Responsible for Corrective Action: Susan Collins, Director of Financial Aid Completion Date: October 17, 2025 Linda Scholting CFO 10/29/2025 Doc Management Response: Management has updated notification processes to ensure appropriate and timely notifications are sent to students.
Finding 2025-002 Condition Of 25 students tested, the status date for one selected student was not reported in a timely manner on the campus level in the National Student Loan Data System (NSLDS). The sample was not statistically valid. Corrective Action Plan To address this issue, the Registrar’s O...
Finding 2025-002 Condition Of 25 students tested, the status date for one selected student was not reported in a timely manner on the campus level in the National Student Loan Data System (NSLDS). The sample was not statistically valid. Corrective Action Plan To address this issue, the Registrar’s Office will adjust the final spring submission date or add a fifth submission to ensure all spring updates are captured. This action resolves timing gaps caused by the non-term summer and the 60+ day interval between spring and fall semesters. Name(s) of Contact Person(s) Responsible for Corrective Action: Denise Ellis, Registrar Anticipated Completion Date: Spring submission dates will be modified or added by November 1, 2025 Linda Scholting CFO 10/29/2025 Management Response: Management has adjusted processes to ensure all student updates are correctly captured.
Finding 2025-001 Condition During the year, there were no documented internal controls in place over the Title IV refund calculations. In the sample of 5 students who withdrew from the University, there was one student for whom the return was miscalculated. The result was too much aid being refunded...
Finding 2025-001 Condition During the year, there were no documented internal controls in place over the Title IV refund calculations. In the sample of 5 students who withdrew from the University, there was one student for whom the return was miscalculated. The result was too much aid being refunded. The sample was not statistically valid. Corrective Action Plan To address this issue, the Title IV Return of Funds Policy has been updated to strengthen accountability and compliance. All R2T4 calculations will be completed by the Financial Aid Counselor and reviewed by the Director, with signatures documenting internal controls. A checklist and quarterly reviews will ensure accuracy, and ERP integration within Ellucian Colleague, set for full implementation by October 31, 2025, will automate calculations and improve compliance monitoring. Name(s) of Contact Person(s) Responsible for Corrective Action: Susan Collins, Director of Financial Aid Anticipated Completion Date: October 31, 2025 Linda Scholting CFO 10/29/2025
The cafeteria manager will reconcile meals served monthly to verify that the numbers match and are verified to actual meals served starting in the 2025-26 School Year.
The cafeteria manager will reconcile meals served monthly to verify that the numbers match and are verified to actual meals served starting in the 2025-26 School Year.
The District Cafeteria Manager, Melanie Pardini, corrected this procedure for fiscal year 2025-26 and has the process in place going forward for each fiscal year.
The District Cafeteria Manager, Melanie Pardini, corrected this procedure for fiscal year 2025-26 and has the process in place going forward for each fiscal year.
Management agrees with the auditors’ finding and their recommendation. In August 2025, $712 of Federal Pell Grant funds were awarded to the first student in question and $260 of Federal Pell Grant funds were returned to the Department of Education for the fifth student in question. Since the remaini...
Management agrees with the auditors’ finding and their recommendation. In August 2025, $712 of Federal Pell Grant funds were awarded to the first student in question and $260 of Federal Pell Grant funds were returned to the Department of Education for the fifth student in question. Since the remaining three students were due additional Unsubsidized Federal Direct Loan funds, the College awarded additional institutional aid of $62, $93, and $93 to students two, three, and four, respectively. The Student Financial Aid Director will communicate with the Online Education Director and/or the Registrar to verify semester and enrollment dates and attend additional training webinars on R2T4 calculations hosted by the Department of Education. Anticipated Completion Date:The corrective action was completed in August 2025. Contact Person Brian Rains, Director of Financial Aid 417-268-6045
Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action tak...
Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Augustana intends to modify the NSC/NSLDS monthly data file to ensure that campus and program enrollment dates are pulled from the appropriate data fields in the student information system. Additionally, Augustana intends to implement a step in the withdrawal process to ensure the change in status is reported accurately and timely. Name of the contact person responsible for corrective action: John Cage at johncage@augustana.edu Planned completion date for corrective action plan: January 30, 2026
2025-002 – Child Nutrition Cluster – Eligibility – The District is aware of the missing eligibility documents for the Child Nutrition program and will implement new procedures and a plan to reduce the missing documentation. Responsible Officials – Heidi Engel, Enrollment & Transportation Coordinator...
2025-002 – Child Nutrition Cluster – Eligibility – The District is aware of the missing eligibility documents for the Child Nutrition program and will implement new procedures and a plan to reduce the missing documentation. Responsible Officials – Heidi Engel, Enrollment & Transportation Coordinator, and Jessica Christensen, District Food Service Manager Anticipated Completion Date – The District will correct this in the subsequent fiscal year.
Finding 2025-005 Lack of Internal Controls over Activities Allowed or Unallowed, Allowable Costs/Cost Principles Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Invoices will be approved for payment by the person who receives the product and then approved also by th...
Finding 2025-005 Lack of Internal Controls over Activities Allowed or Unallowed, Allowable Costs/Cost Principles Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Invoices will be approved for payment by the person who receives the product and then approved also by the food service coordinator. No unallowable costs will be paid for with food service revenue. Proposed Completion Date: Fiscal Year 2026.
Finding 2025-004 Lack of Internal Controls over Reporting Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Records will be reviewed monthly by two individuals to ensure they are complete. Back up documentation shall be kept in a secure location where at least two oth...
Finding 2025-004 Lack of Internal Controls over Reporting Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Records will be reviewed monthly by two individuals to ensure they are complete. Back up documentation shall be kept in a secure location where at least two other budget supervisors are aware and have access to same. Proposed Completion Date: Fiscal Year 2026
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Will need to meet with academic records and determine if Doctorate program Dissertation 1-hour course can be coded and reported as full time to NSLDS Person Responsible for Corrective Action Plan: ...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Will need to meet with academic records and determine if Doctorate program Dissertation 1-hour course can be coded and reported as full time to NSLDS Person Responsible for Corrective Action Plan: Academic Records / Regina Bolding Harned - Registrar / Allison Sullivan – Director of Financial Aid Anticipated Date of Completion: 12/5/25
The audit finding indicated that direct certifications were not completed as required attributed to turnover in the Food Service Director position. There certifications may or may not have been done, we were not able to provide documentation to prove this. The new Food Service Director (Billie Jo Da...
The audit finding indicated that direct certifications were not completed as required attributed to turnover in the Food Service Director position. There certifications may or may not have been done, we were not able to provide documentation to prove this. The new Food Service Director (Billie Jo Davis) is in place and has a strong understanding of the NSLP program and its requirements. Direct Certifications have been scheduled and placed on calendars for her and the finance team to ensure the files are completed and the documentation is properly stored moving forward. Submitting a direct certification file monthly will allow us to have up to date information on our students.
Corrective Action Management has issued a formal response to HUD’s Findings dated August 12, 2024, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of December 3, 2025. The Authority’s Executive Director, Julius Howard has assumed the responsib...
Corrective Action Management has issued a formal response to HUD’s Findings dated August 12, 2024, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of December 3, 2025. The Authority’s Executive Director, Julius Howard has assumed the responsibility of continued execution of the corrective actions.
KCU will meet the requirements in accordance with 34 CFR Section 685.309 by reviewing the enrollment reporting submitted to NSLDS through the National Student Clearinghouse (NSC) each month and comparing to KCU’s student information system to ensure that all dates and information submitted for the m...
KCU will meet the requirements in accordance with 34 CFR Section 685.309 by reviewing the enrollment reporting submitted to NSLDS through the National Student Clearinghouse (NSC) each month and comparing to KCU’s student information system to ensure that all dates and information submitted for the month is accurate and timely. Contact Person: Cindy Miller Anticipated Completion Date: August 15, 2025
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