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Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury and Bristol County, Massachusetts. Corrective Action Planned: To ensure the accuracy of ARPA reporting, and all Federal Grants, a reconciliation process w...
Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury and Bristol County, Massachusetts. Corrective Action Planned: To ensure the accuracy of ARPA reporting, and all Federal Grants, a reconciliation process will be implemented and followed by all involved. Anticipated Completion Date: April 30, 2026 Contact: Nicole Pearsall, Town Accountant
Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement:...
Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement: Procurement, Suspension, and Debarment Type of Finding: Material Weakness and Instance of Noncompliance Department’s Management Response: Ventura County Health Care Agency (HCA) management agrees with the recommendation for the County to strengthen its policies and procedures to ensure that the verification of the debarment and suspension is documented and retained, the history of procurement transactions is documented and retained in its official record, and that contracts include all applicable provisions of 2 CFR 200 Appendix II. View of Responsible Officials and Corrective Action: HCA Management will implement documentation procedures to support the evaluation and selection of vendors. These procedures will include but are not limited to, ensuring that debarment and suspension verifications are properly documented and retained, procurement transaction histories are maintained in official records, and all contracts include the applicable provisions required under 2 CFR 200 Appendix II. Name of Responsible Persons: Mike Taylor, HCA CFO John Fankhauser, HCA Director Implementation Date: March 2026 – Add documentation of suspension and debarment check for applicable contracts.
Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements...
Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: VCPH Management agrees with the recommendation for the Department to strengthen its policies and procedures to ensure all required reports are reviewed, approved and retained as evidence in the applicable grant folder. View of Responsible Officials and Corrective Action: VCPH Management will implement a requirement that all applicable reports must include documented review and approval (e.g. email approval, signed cover sheet, or workflow confirmation) before submission and retention of such approval evidence in the applicable grant folder location. Name of Responsible Persons: Maria Macias, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: April 2026
Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement:...
Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement: Other - Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Department’s Management Response: Management agrees with the recommendation to enhance internal controls to ensure federal expenditures are reported accurately and completely on the SEFA in accordance with the Uniform Guidance. View of Responsible Officials and Corrective Action: To ensure compliance with §200.510(b) of the Uniform Guidance, the Auditor Controller’s Office will issue additional detailed instructions clarifying the period covered by the amounts to be reported when requesting departmental information for the County’s SEFA. These clarifications will support consistency, accuracy, and improved internal controls over federal expenditure reporting. Name of Responsible Persons: Jason McGuire, Deputy Director, Auditor-Controller Implementation Date: August 2026
Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Materia...
Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees and acknowledges the findings related to the application and review of sliding fee discounts under the Self-Pay Discount Program. The Department recognizes the importance of consistent application of sliding fee discount schedules and proper documentation of review processes to ensure full compliance with federal requirements. The Department is committed to maintaining strong internal controls and ensuring adherence to all applicable policies, procedures, and regulatory standards governing the Sliding Fee Discount Program. View of Responsible Officials and Corrective Action: HCA Management agrees with the finding and will implement corrective actions to strengthen internal controls and ensure consistent application of the sliding fee discount program. The following actions will be taken: • Reinforcement of Policies and Procedures: Re-educate all applicable staff on existing sliding fee discount program policies, including proper calculation and application of discounts. First re-education session was held on February 4, 2026. • Standardization of Workflow: Update and implement standardized workflows and job aids within the registration and billing processes to ensure discounts are applied accurately and consistently. Standardized workflows completed on February 2, 2026. • Enhanced Review and Oversight: Establish a formalized secondary review process for sliding fee discount determinations, including required documentation and supervisory sign-off. Supervisor sign off on sliding fee applications by April 1, 2026. • Ongoing Training: Incorporate sliding fee discount program requirements into onboarding and annual refresher training for relevant staff beginning April 1, 2026. • Audit and Monitoring: Conduct monthly internal audits of sliding fee discount applications to monitor compliance and identify any trends or gap by May 1, 2026. These corrective actions are designed to ensure compliance with federal requirements, improve consistency in application, and strengthen overall internal controls. Name of Responsible Persons: Octavius Gonzaga, Ambulatory Care CFO – Establishes sliding fee discount program policy, procedures, and fee schedules. Erika Herincx, Ambulatory Care Revenue Cycle Manager – Responsible for the oversight of the training program and ensures the listed activities in the Corrective Action Plan are executed. Implementation Date: February 4 - March 30, 2026 – Training of front-end staff and clinic management. April 1, 2026 – Implementation of supervisor sign off for each sliding fee application. April 1, 2026 – Re-Training of Medical Billing Specialists on adjustments. May 1, 2026 – Monthly sampling of encounters December 1, 2026 – Year-to-date report and internal audit
Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITP...
Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITPPS-21029, 18-DRWD-23003, 21-CDBG-HK-0010 Award Year: 2022, 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: Management agrees with the recommendation to revise its procedures to include evidence documenting the individual who reviewed and approved required reports prior to submission. View of Responsible Officials and Corrective Action: a. With regards to the CDBG-CV2 and CDBG-MIT reports managed by the County Executive Office Community Development Division, procedures were revised beginning in April 2025 due to prior year findings 2024-007 and 2024-008 to incorporate documented review and approval requirements for all applicable federally required reports. These enhanced internal controls are being phased in across all relevant reporting processes, with full implementation completed by the end of June 2025. These changes are intended to ensure that evidence of review and approval is consistently retained and that reporting is accurate, complete, and compliant with federal requirements. The reports identified in the finding were completed prior to the stated corrective action. b. With regards to the VC Heal Activity reports managed by Ventura County Workforce Development (VCWD) management, the required reports were prepared by the subrecipient (Career TEAM) using the standardized HCD format and underwent multiple levels of review, the County acknowledges that documentation of the specific individual review and approval prior to submission was not consistently retained. To strengthen internal controls to ensure all required reports include documented evidence of review and approval prior to submission, VCWD management will: • Implement a standardized review and approval protocol requiring documented sign‑off by designated VCWD management prior to submission. • Require Career TEAM to use a formal certification or routing process identifying the preparer and reviewer. • Maintain centralized documentation identifying the report preparer, reviewer/approver, and date of review. • Incorporate these requirements into internal procedures and contractor guidance. • Conduct periodic internal monitoring to verify compliance. Name of Responsible Persons: a. Kimberlee Albers, Deputy Executive Officer b. VCWD staff responsible for the CDBG program Career TEAM (Subrecipient – Report Preparation) Implementation Date: a. April – June 2025 b. April 2026
Finding 2025-004 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...
Finding 2025-004 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, B-24-UC-06-0507, 95-6000807 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Department’s Management Response: The County Executive Office agrees with the recommendation to strengthen its internal controls to ensure compliance with wage rate requirements. View of Responsible Officials and Corrective Action: The County Executive Office Community Development Division will conduct a comprehensive review and update of its Federal Labor Standards Policy and Procedure (FLSPP), with completion targeted no later than July 1, 2026. The updated FLSPP will include a requirement for County staff to obtain and retain certified payroll submissions monthly for all construction activities subject to prevailing wage requirements. Although the formal policy update will not be effective until July 1, staff will begin implementing this control immediately. Name of Responsible Persons: Kimberlee Albers, Deputy Executive Officer Tracy McAulay, Housing Solutions Director Ying Vang, Management Analyst (Community Development Block Grant) Michael Skinner, Management Analyst (HOME Investment Partnerships Program) Implementation Date: April 2026
Finding 2025-003 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...
Finding 2025-003 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, B-24-UC-06-0507, 95-6000807 Award Year: 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: The County Executive Office Community Development Division agrees with the recommendation to revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. View of Responsible Officials and Corrective Action: Procedures were revised beginning in April 2025 due to prior year findings 2024-007 and 2024-008 to incorporate documented review and approval requirements for all applicable federally required reports. These enhanced internal controls are being phased in across all relevant reporting processes, with full implementation completed by the end of June 2025. These changes are intended to ensure that evidence of review and approval is consistently retained and that reporting is accurate, complete, and compliant with federal requirements. The reports identified in the finding were completed prior to the stated corrective action. Name of Responsible Persons: Kimberlee Albers, Deputy Executive Officer Implementation Date: April – June 2025
Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: A...
Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Activities Allowable or Unallowed and Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: HCA’s Ventura County Public Health (VCPH) Management agrees with the recommendation to strengthen the established policies and procedures to ensure all timecards consistently document evidence of supervisor approval. View of Responsible Officials and Corrective Action: The timesheet identified during this audit were submitted in the County’s payroll system prior to the completion of the 2024 fiscal year audit and related finding 2024-003; therefore, the related corrective actions had not yet been implemented at the time of submission. In response to the prior year’s finding, VCPH Management implemented enhanced controls to ensure compliance with timecard approval requirements moving forward from that date. Payroll staff now sends reminder notifications to supervisors, managers, and VCPH Management before and after each pay period closing to identify and resolve unapproved timecards. Management has also reinforced expectations through additional training for supervisors and managers. When a primary supervisor is unavailable, the established alternate approver process will be used to ensure timely approvals. VCPH Management will continue monitoring compliance with these procedures, and these requirements will be reviewed again with all supervising staff at the next scheduled WIC Supervisor Meeting. Name of Responsible Persons: Laura Flores, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: May 1, 2025 – Instructions were provided to all supervisors at the WIC Supervisor Team Meeting May 7, 2026 – Timecard instructions will again be discussed at the WIC Supervisor Team Meeting
Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Procurement and Su...
Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control over Compliance and Instance of Non-Compliance Department’s Management Response: Ventura County Health Care Agency (HCA) management agrees with the recommendation for the County to strengthen its policies and procedures to ensure that the verification of the debarment and suspension is documented and retained, the history of procurement transactions is documented and retained in its official record, and that contracts include all applicable provisions of 2 CFR 200 Appendix II. View of Responsible Officials and Corrective Action: HCA Management will implement documentation procedures to support the evaluation and selection of vendors. These procedures will include but are not limited to, ensuring that debarment and suspension verifications are properly documented and retained, procurement transaction histories are maintained in official records, and all contracts include the applicable provisions required under 2 CFR 200 Appendix II. Name of Responsible Persons: Mike Taylor, HCA CFO John Fankhauser, HCA Director Implementation Date: March 2026 – Add documentation of suspension and debarment check for applicable contracts April 2026 – Include applicable provisions described in 2 CFR 200 Appendix II to contracts
The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete tim...
The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete timely vouchers will occur. This new process will enable the fiscal employees responsible for vouchering to complete their functions in a timely manner.
KEDREN'S PRIMARY CARE CLINICAL MANAGEMENT HAS IMPLEMENTED SEVERAL STEPS TO ENSURE THAT THE PATIENTS ARE BILLED PROPERLY IN ACCORDANCE WITH THE SLIDING FEE SCHEDULE. THESE CHANGES WILL BE IMPLEMENTED AND MONITORED
KEDREN'S PRIMARY CARE CLINICAL MANAGEMENT HAS IMPLEMENTED SEVERAL STEPS TO ENSURE THAT THE PATIENTS ARE BILLED PROPERLY IN ACCORDANCE WITH THE SLIDING FEE SCHEDULE. THESE CHANGES WILL BE IMPLEMENTED AND MONITORED
Need Analysis Planned Corrective Action: The institution is moving to automated loan packaging by the Power FAIDS financial aid management system, which packages the loan based on grade level and remaining unmet financial need. Therefore, if a student’s remaining need is less than the available subs...
Need Analysis Planned Corrective Action: The institution is moving to automated loan packaging by the Power FAIDS financial aid management system, which packages the loan based on grade level and remaining unmet financial need. Therefore, if a student’s remaining need is less than the available subsidized eligibility, the system will only package up to the remaining need. Furthermore, as a second quality assurance check, a rule has been written in the PowerFAIDS financial aid management system that will flag any student that has been awarded sub over need. Person Responsible for Corrective Action Plan: Justin Pichey, Director of Financial Aid Anticipated Date of Completion: This has already been implemented for fiscal year 2026-2027.
Credit Balances Held Beyond Payment Period Planned Corrective Action: Ohio Christian University has implemented procedures to ensure that all Title IV credit balances are identified and released to students within 14 days of the credit balance occurring, in compliance with federal regulations. The F...
Credit Balances Held Beyond Payment Period Planned Corrective Action: Ohio Christian University has implemented procedures to ensure that all Title IV credit balances are identified and released to students within 14 days of the credit balance occurring, in compliance with federal regulations. The Financial Aid Office will run weekly credit balance reports following each disbursement to identify any student accounts with a Title IV credit balance. These reports will be reviewed jointly by the Financial Aid and Student Accounts offices to confirm eligibility and authorize timely refunds. As an ongoing quality assurance measure, supervisory review will be conducted monthly to verify compliance with the 14-day requirement, and any exceptions will be documented and addressed immediately. Staff training has been enhanced to reinforce regulatory requirements and internal timelines related to credit balance processing. Person Responsible for Corrective Action Plan: Justin Pichey, Director of Financial Aid & Chelsie Hedrick, Senior Accountant Anticipated Date of Completion: This was implemented starting with the Spring 2026 semester.
Finding Number: 2025‐004 Program Name/Assistance Listing Title: Indian School Equalization Program, Special Education Cluster (IDEA) Assistance Listing Number: 84.425, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The Schoo...
Finding Number: 2025‐004 Program Name/Assistance Listing Title: Indian School Equalization Program, Special Education Cluster (IDEA) Assistance Listing Number: 84.425, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School lacked adequate internal controls over disbursements, journal entries, and payroll. - Efforts to maintain proper supporting documentation for various transactions must improve.Staff training to highlight the importance of following procedures and maintaining supporting documentation for all transactions has already occurred and will be held multiple times in the future. - Two current employees have unusual employment status that makes recalculating their pay difficult; they are part‐time, but on salary.
Finding Numbers: 2025‐003, 2024‐003, 2023‐003 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Numbers: 84.425 Contact Person: Holena Lebron, Superintendent An􀆟cipated Completion Date: June 30, 2026 Planned Corrective Action: The School has not been abl...
Finding Numbers: 2025‐003, 2024‐003, 2023‐003 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Numbers: 84.425 Contact Person: Holena Lebron, Superintendent An􀆟cipated Completion Date: June 30, 2026 Planned Corrective Action: The School has not been able to devote proper resources and training to ensure capital assets are accurate and up to date. - The staff member assigned to make improvements in this area since the fiscal year 2023‐24 audit is no longer employed by the School. Additional staff and training are needed. - The School will seek to replace needed staff and reassign duties regarding the tracking of capital assets, including the assigning of identification numbers and inventory procedures.
Finding Numbers: 2025‐002, 2024‐002 Program Name/Assistance Listing Titles: Indian School Equalization; Administrative Cost Grants for Indian Schools, Special Education Cluster (IDEA) Assistance Listing Numbers: 15.042; 15.046, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Complet...
Finding Numbers: 2025‐002, 2024‐002 Program Name/Assistance Listing Titles: Indian School Equalization; Administrative Cost Grants for Indian Schools, Special Education Cluster (IDEA) Assistance Listing Numbers: 15.042; 15.046, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School’s internal controls over procurement of goods and services were not adequate. - A change in office staff just before the audit visit made finding documentation related to procurement difficult. Efforts to improve in this area have been made and will continue to be a focus of the administration. Procurement procedures are in place and are being followed, but record keeping remains a challenge. A new hire in this area with training emphasis is needed.
Finding Numbers: 2025‐001, 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School did not complete character ...
Finding Numbers: 2025‐001, 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School did not complete character reinvestigations timely for all employees. - An internal review identified that employee suitability determinations and five‐year reinvestigations were not consistently tracked. - To address this, the administration will review all personnel files to identify employees who are due or overdue for reinvestigation. Any overdue determinations will be completed immediately. A tracking system will be implemented to monitor the five‐year requirement and ensure reinvestigations are completed on time moving forward. Periodic file reviews will also be conducted to maintain compliance.
We will review procedures and plan to make changes to improve internal control when possible.
We will review procedures and plan to make changes to improve internal control when possible.
We will review procedures and plan to make changes to improve internal control when possible.
We will review procedures and plan to make changes to improve internal control when possible.
Finding 1204849 (2025-002)
Material Weakness 2025
NAMI Chicago acknowledges the finding and has revised the finance policy as of January 1, 2026 to clearly define micro-purchase thresholds and procedures for micropurchases, simplified acquisition thresholds and procedures for simplified acquisitions, formal procurement methods for use when transact...
NAMI Chicago acknowledges the finding and has revised the finance policy as of January 1, 2026 to clearly define micro-purchase thresholds and procedures for micropurchases, simplified acquisition thresholds and procedures for simplified acquisitions, formal procurement methods for use when transactions exceed acquisition threshold and noncompetitive procurement methods. Management will monitor procurement activity for compliance with the updated policy.
Finding 1204848 (2025-001)
Material Weakness 2025
NAMI Chicago acknowledges the finding regarding documentation of approvals for expenses charged to federal awards. The exceptions identified occurred during the first half of the fiscal year, prior to the January 1, 2025, implementation of our enhanced Internal Control and Disbursement Policy develo...
NAMI Chicago acknowledges the finding regarding documentation of approvals for expenses charged to federal awards. The exceptions identified occurred during the first half of the fiscal year, prior to the January 1, 2025, implementation of our enhanced Internal Control and Disbursement Policy developed in direct response to the FY24 audit recommendations, which were finalized and communicated in early 2025. Since January 1, 2025, NAMI Chicago has successfully implemented a mandatory digital approval workflow for all grant-funded expenditures to ensure contemporaneous documentation. Management is confident that these strengthened protocols, which were fully operational for the latter half of FY2025 and continue to date, have resolved the underlying issue. We expect no further instances of this finding in future audit cycles.
Finding 2025-001 Condition The University did not notify the National Student Loan Data System (NSLDS) in a timely manner for four students with status changes. Corrective Action Plan 1. Finding: Incorrect Status Date Reported to NSC/NSLDS for a withdrawn student Corrective Actions: • Root Cause Ana...
Finding 2025-001 Condition The University did not notify the National Student Loan Data System (NSLDS) in a timely manner for four students with status changes. Corrective Action Plan 1. Finding: Incorrect Status Date Reported to NSC/NSLDS for a withdrawn student Corrective Actions: • Root Cause Analysis: A review was conducted to determine why NSC/NSLDS received the incorrect date despite Colleague displaying the correct withdrawal date of 3/20/2025. The analysis confirmed that the Colleague reporting process pulls the date from the course drop/withdrawal field rather than the student status withdrawal date screen. According to system documentation, “SITX determines the enrollment status, enrollment status start date, and the anticipated graduation date for the students included in the extract. If the enrollment status changes during the reporting period since the last census date, the status change date is calculated from schedule changes and hiatus record information.” • Process Improvement: o Staff have been instructed to ensure that all relevant screens reflect the correct status change date prior to reporting. o Documentation is being developed outlining the withdrawal process workflow, including all screens requiring updates. This will promote consistency and serve as a reference for future staff transitions. 2. Finding: Failure to Report Three Graduates to NSLDS Within the 60 Day Requirement Corrective Actions: • Root Cause Analysis: The University Registrar contacted the NSC to investigate the delay. Although the NSC Degree Verify file was submitted within the required timeframe, it was determined that the “G Not Applied” process on the NSC site was not completed promptly by Registrar’s Office staff, resulting in the late NSLDS reporting. • Process Redesign: The University Registrar is working with Gannon IT Services to develop a “Graduates Only” reporting process directly from Colleague. This enhancement will eliminate reliance on the NSC “G Not Applied” step, which has been a recurring compliance challenge. This new process will be implemented no later than July 1, 2026. Until then, the “G Not Applied” list will be processed within 10 days of processing availability (at times the G Not Applied cannot be updated while an Enrollment file submission is pending acceptance). • Proactive Audit Measures: Given the significant staffing transitions and shifts in reporting responsibilities over the past year, an internal audit of the 2025–2026 reporting completed to date is underway, in collaboration with the NSC Audit Department, to determine the full extent of any additional reporting deficiencies that may have carried into the new academic year. 3. As previously stated in the Summary Schedule of Prior Audit Findings for the Year-Ended June 30, 2024 Update, the following corrective actions are being initiated: • Additional staff have been designated to ensure that at least three individuals possess the knowledge and system access required to submit reports and process corrections. • All designated staff are required to complete NSC-provided training to ensure full understanding of reporting requirements and procedures. • Each staff member must submit test reports and review resulting errors using the NSC test submission process, working closely with assigned NSC analysts to demonstrate competency in accurate reporting and effective error resolution. Name(s) of Contact Person(s) Responsible o Barbara Helms, University Registrar – primary responsibility for enrollment reporting submissions, back-up for G reporting o Heidi Thomas, Processing and Data Specialist – assists with enrollment error report cleanup, secondary for enrollment reporting submissions, additional back-up for G reporting o Ashley Dinger, Academic Records and Graduation Specialist – primary responsibility of the G reporting, additional back-up for enrollment reporting. • Although documentation exists from the previous corrective action plan, it has been determined that it is not sufficiently detailed. New documentation is being developed to ensure that any individual responsible for these processes in the future has the necessary tools and guidance to meet all regulatory requirements. Estimated timeline for corrective action to be implemented: April 2026
FINDING 2025-007 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We have revised our award period start and end dates to align or fall within range of our loan period code start and end dates when reporting to COD. This alignment ensures that all reported disb...
FINDING 2025-007 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We have revised our award period start and end dates to align or fall within range of our loan period code start and end dates when reporting to COD. This alignment ensures that all reported disbursements meet federal timing requests and reduces the risk of COD rejects or compliance findings. Anticipated Completion Date: March 31, 2026
FINDING 2025-006 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: To resolve the finding of loan period academic end dates being inaccurately reported, we now utilize system forms that allow us to identify and batch-correct any student record with incorrect dat...
FINDING 2025-006 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: To resolve the finding of loan period academic end dates being inaccurately reported, we now utilize system forms that allow us to identify and batch-correct any student record with incorrect dates. This process enhances data accuracy, ensures proper reporting, prevents COD rejects and reduces the risk of future compliance issues. Anticipated Completion Date: Already completed
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