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Finding No. 2025-001 – Significant Deficiency and Noncompliance: Reporting Corrective Action The corrective action that will be taken is that Enrollment Information and Status Changes will be reported timely to NSLDS. The following will support this effort: 1. Address Systematic Issues 2. Enhance St...
Finding No. 2025-001 – Significant Deficiency and Noncompliance: Reporting Corrective Action The corrective action that will be taken is that Enrollment Information and Status Changes will be reported timely to NSLDS. The following will support this effort: 1. Address Systematic Issues 2. Enhance Staff Training 3. Implement Regular Monitoring and Auditing Persons Responsible for Corrective Action The corrective action plan will be completed by Corry Unis, Vice President for Enrollment Management and Diana Draper, Executive Director of Financial Aid. Anticipated Completion Date: May 31, 2026 The University has already reported 12 of the 21 students to NSLDS. The University will update the enrollment reporting to NSLDS for the remaining 9 students impacted. The University will determine the principal cause of the discrepancy and implement a combination of controls, monitoring, and training to ensure accuracy and timeliness of future reporting.
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of mont...
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of monthly audits performed by service line leaders will be reported to senior leadership. An internal audit will be done by the compliance team and presented to leadership on a quarterly basis. All appropriate admitting staff will go through training to reinforce our slide process and review procedures for all FQHC services.
Grant salaries and purchase orders will be reviewed for proper accounting. Monthly review with the grant coordinator and the business office will occur to verify appropriate charges.
Grant salaries and purchase orders will be reviewed for proper accounting. Monthly review with the grant coordinator and the business office will occur to verify appropriate charges.
The auditor has confirmed in the ACFR that we have worked with the software provider and identified the issue with the edit check worksheets not correctly reporting meals on a daily basis. The software has been adjusted.
The auditor has confirmed in the ACFR that we have worked with the software provider and identified the issue with the edit check worksheets not correctly reporting meals on a daily basis. The software has been adjusted.
Finding 1205435 (2025-001)
Material Weakness 2025
Department of Treasury Federal Financial Assistance Listing # 21.027 Department of Health and Human Services Federal Financial Assistance Listing #93.493 Procurement, Suspension & Debarment Significant Deficiency in Internal Control over Compliance and Compliance Finding Summary: Our testing over pr...
Department of Treasury Federal Financial Assistance Listing # 21.027 Department of Health and Human Services Federal Financial Assistance Listing #93.493 Procurement, Suspension & Debarment Significant Deficiency in Internal Control over Compliance and Compliance Finding Summary: Our testing over procurement suspension and debarment identified two contracts over $25,000 where some contract provisions required by Uniform Guidance were not included. Responsible Individuals: Jamie Schaefer, John Neth Corrective Action Plan: The organization will review and strengthen the controls surrounding procurement, suspension, and debarment. The Organization will develop a Required Contract Provision Checklist/Reference Sheet that summarizes the requirements in 2 CFR § 200 Appendix II that will be utilized during the grant contract review. Anticipated Completion Date: June 30, 2026
Finding 1205432 (2025-002)
Material Weakness 2025
Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Secti...
Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Refresher training sessions will be fully completed for all Medicaid staff by the end of January 2026. Documentation standards and quality review processes are already in effect, with ongoing monitoring. Angel Carpenter and Goldie Davis - Medicaid Supervisors All Medicaid caseworkers will complete targeted refresher training on key eligibility and budgeting rules, including the use of online verification systems, accurate income and deduction calculations, household composition, recertification processes, and proper case documentation standards. Training will be delivered through a combination of state Learning Gateway courses, webinars, and internal sessions, with knowledge checks to confirm understanding. Staff will be reminded that “if it’s not documented, it didn’t happen.” Standardized documentation templates have been created and are now required for all cases to ensure thorough, clear, and consistent case notes. Second-party case reviews will continue and be expanded as needed to monitor ongoing accuracy. Case errors and lessons learned will be regular agenda items at monthly staff meetings, with emphasis on double-checking determinations before authorizing or releasing cases in NC FAST. Dedicated weekly time will be protected for staff to work pending verifications and system reports, with supervisory review. Section II - Financial Statement Findings 8/14/2025 Nikki Stanton, Finance Director The Nash County Finance Director was appointed effective April 14, 2025. Since that time, Finance has undertaken the following measures to strengthen operations and internal controls: • Reclassified job duties to better align responsibilities with organizational needs and improve efficiency. • Implemented additional internal controls to enhance the reliability and accuracy of financial processes. • Recruited and onboarded a dedicated Accountant to support the Accounting Manager. These changes have enabled the Accounting Manager to concentrate on performing timely reconciliations and preparing accurate journal entries, thereby improving the overall timeliness and quality of financial reporting. For the Year Ended June 30, 2025 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 188
The data collection form for the year ended June 30, 2024, was not filed timely. This late filing was due to the 2024 audit being completed late because of significant staff turnover. To prevent a late filing in the future, management is working to and has filled several vacant positions to help wit...
The data collection form for the year ended June 30, 2024, was not filed timely. This late filing was due to the 2024 audit being completed late because of significant staff turnover. To prevent a late filing in the future, management is working to and has filled several vacant positions to help with staff workload.
Planned Corrective Action: Management will strengthen procurement policies, procedures, and documentation practices to ensure compliance with Uniform Guidance (2 CFR 200.318–200.327) and TxGMS general procurement standards. Actions will include: updating the procurement policy to clarify procurement...
Planned Corrective Action: Management will strengthen procurement policies, procedures, and documentation practices to ensure compliance with Uniform Guidance (2 CFR 200.318–200.327) and TxGMS general procurement standards. Actions will include: updating the procurement policy to clarify procurement methods and dollar thresholds; adopting a standardized procurement justification template for sole source determinations that requires documented rationale and supervisory approval; implementing a required procurement file checklist that documents the procurement method used, vendor selection process, quotes or bids obtained, and retained supporting documentation; instituting supervisory review and sign off of procurement classification and supporting documentation prior to award approval and payment; providing targeted training for Programs, Finance, and Procurement staff on procurement rules, sole source justification, and simplified acquisition documentation requirements; and performing a retrospective review of the two identified procurements to complete or document required supporting evidence and remediate any gaps. Finance will perform periodic testing of procurement files to verify adherence to the updated procedures and report findings to management and the Audit Committee. Responsible Parties: Kyle Bolls, Controller Ryan Parks, CFO Estimated Completion Date: September 30, 2026
Improve Controls over Subrecipient Monitoring Name of contact person: Connie DeKemper Anticipated completion date: 06/30/2026 Condition – During our audit, we noted the County did not complete the required monitoring until six months after the fiscal year end. Response - Subrecipient monitoring will...
Improve Controls over Subrecipient Monitoring Name of contact person: Connie DeKemper Anticipated completion date: 06/30/2026 Condition – During our audit, we noted the County did not complete the required monitoring until six months after the fiscal year end. Response - Subrecipient monitoring will be completed during the fiscal year.
Improve Controls over Earmarking Name of contact person: Connie DeKemper Anticipated completion date: 06/30/2026 Condition – During our audit, we noted that the County utilized 74.4% of the expenditures on out-of-school youth, a deficiency of .6%. Furthermore, the County utilized 15.8% of youth expe...
Improve Controls over Earmarking Name of contact person: Connie DeKemper Anticipated completion date: 06/30/2026 Condition – During our audit, we noted that the County utilized 74.4% of the expenditures on out-of-school youth, a deficiency of .6%. Furthermore, the County utilized 15.8% of youth expenditures for paid and unpaid work experience, a 4.2% deficiency. Response - Expenditures will be reviewed on a monthly basis to ensure earmarking requirements are met. If not, a waiver for the earmarking requirements will be requested from the grantor.
Improve Internal Controls over Reporting Name of contact person: Connie DeKemper Anticipated completion date: 12/31/2026 Condition – During our audit, we noted the quarterly report ended March 31, 2025, was not filed. The expenditures for that period were included on the quarterly report ended June ...
Improve Internal Controls over Reporting Name of contact person: Connie DeKemper Anticipated completion date: 12/31/2026 Condition – During our audit, we noted the quarterly report ended March 31, 2025, was not filed. The expenditures for that period were included on the quarterly report ended June 30, 2025. Response - The County is in the process of reviewing the terms of the subrecipient agreement for reporting and is developing systems for timely reporting.
I. Procurement, Suspension and Debarment Evidence of controls over Suspension and Debarment Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressionally...
I. Procurement, Suspension and Debarment Evidence of controls over Suspension and Debarment Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressionally Recommended Awards Federal Agency: Department of Health and Human Services Department of Justice Recommendation: The Corporation should retain documentation to support completeness and accuracy of the vendor list submitted for screening and the results obtained to support the screening process to ensure that no suspended or debarred vendors are utilized by the Corporation prior to entering into transactions. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation will formalize the system of record and end-to-end data flow, implement monthly reconciliations to confirm the completeness of the vendor population submitted for screening, and introduce data validation checks to ensure the accuracy of key vendor information. Supporting documentation will be centrally maintained to evidence control execution, and related policies and procedures will be updated with targeted training to promote consistent and sustainable application. Collectively, these enhancements are designed to mitigate the risk of engaging with suspended or debarred vendors. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Allison Dennison, Director, Compliance Operations, Allison.Dennison@umm.edu
I. Procurement, Suspension and Debarment Incomplete Federal Requirements within Procurement Policies Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congre...
I. Procurement, Suspension and Debarment Incomplete Federal Requirements within Procurement Policies Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressionally Recommended Awards Federal Agency: Department of Health and Human Services Department of Justice Recommendation: The Corporation should update its procurement policy to include the provisions required by the Uniform Guidance for purchasing goods and/or services with federal funds. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA, Corporate Financial Reporting and Legal drafted a procurement policy for federal awards. The policy is under review by other relevant stakeholders across UMMS. Anticipated Completion Date – August 31, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
C. Cash Management; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressional...
C. Cash Management; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressionally Recommended Awards Federal Agency: Department of Health and Human Services Department of Justice Recommendation: Management should reassess the design of its controls to ensure documentation is retained that evidences the review and approval of expenditures submitted to the DOJ and DHHS for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. ORSPA and Corporate Financial Reporting are developing standard operating procedures and policies for the required review and reconciliation of grant expenditures per the accounting system to the financial submissions to the granting agency, including requirements for maintaining evidence of the review(s). A shared central repository for financial submissions was created. For each grant, this repository includes the financial submission and evidence of review and approval of the financial report submissions. The ORSPA and Corporate Financial Reporting will monitor the repository and work with grant managers to ensure evidence of financial submission review and approval is maintained. Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Payroll Expenditures Assistance Listing 16.753 – Congressionally Recommended Awards Federal Agency: Department of Justice (DOJ) Recommendation: Management should retain documentation that evidences the revi...
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Payroll Expenditures Assistance Listing 16.753 – Congressionally Recommended Awards Federal Agency: Department of Justice (DOJ) Recommendation: Management should retain documentation that evidences the review and approval of expenditures submitted to the DOJ. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA department created a standard pre-award approval process for all sponsored proposals prior to submission or award acceptance. The pre-award approval process applies to all federal, state, local, private and commercial funding opportunities across all UMMS entities and covers new, renewal, resubmission and supplemental proposals. The pre-award approval process includes review of budgeted expenditures and setup of a specific grant identifier within the accounting system and timekeeping system. Grant managers will be provided with updated policies and standard operating procedures, including the required review and approval of payroll expenditures via review of employee timecards in the Kronos and/or Workforce Management timekeeping systems. In lieu of review of timecards, ORSPA and Corporate Financial Reporting established a shared repository for financial submissions to the granting agencies, payroll reports, and detailed expenditure reports generated from the accounting system. The payroll reports and detailed expenditure reports are made available to grant managers to assist in their review and approval of expenditures included in their financial submissions to the granting agencies. The ORSPA and Corporate Financial Reporting will monitor the repository and work with grant managers to ensure evidence of review of the expenditures included within the financial submission is maintained. Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
Condition: During our testing of controls over payroll, we identified three instances of payroll summary reports lacking an indication of review and approval. Criteria: The Uniform Guidance 2 CFR 200.303 requires auditees to establish and maintain effective internal control over federal awards that ...
Condition: During our testing of controls over payroll, we identified three instances of payroll summary reports lacking an indication of review and approval. Criteria: The Uniform Guidance 2 CFR 200.303 requires auditees to establish and maintain effective internal control over federal awards that provides reasonable assurance that the awards are being managed in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The Organization should have a system of internal control in place to provide reasonable assurance that payroll summary reports are accurate and are being reviewed. Repeat of Prior Year Finding: No. Auditor’s Recommendation: We recommend that payroll summary reports be reviewed and approved prior to completing the payroll process. If the Executive Director is unavailable, another staff member should review and approve the reports so the payroll process can be completed. Management’s Response: Payroll reports will be reviewed and approved by the Executive Director. If the Executive Director is unavailable, another staff member will review and approve the reports. The Executive Director has reviewed and approved all payroll reports to date. Completion Date: March 17, 2026
Finding: 2025-001 Policies and procedures Corrective Action Plan: Management will work to develop, formalize, and implement a complete set of accounting policies and procedures. Responsible Party and Anticipated Completion Date: Elizabeth Cardona, Executive Director June 30, 2027 Finding: 2025-002 N...
Finding: 2025-001 Policies and procedures Corrective Action Plan: Management will work to develop, formalize, and implement a complete set of accounting policies and procedures. Responsible Party and Anticipated Completion Date: Elizabeth Cardona, Executive Director June 30, 2027 Finding: 2025-002 NYSERS submissions Corrective Action Plan: Management will work to submit all overdue ERS submissions as soon as possible. Additionally, Management will work to develop processes and procedures to ensure that future submissions are made timely. Management will attempt to obtain any requisite training for the employee(s) who is charged with this task. Responsible Party and Anticipated Completion Date: Elizabeth Cardona, Executive Director June 30, 2026 Finding: 2025-003 Federal grants Corrective Action Plan: Management will work to develop and implement better and more comprehensive policies and procedures to ensure that its grant accounting and management processes are more accurate, more efficient, and in compliance with HUD regulation. Responsible Party and Anticipated Completion Date: Elizabeth Cardona, Executive Director June 30, 2027
Finding 1205391 (2025-102)
Material Weakness 2025
2025-102 The County did not develop internal control procedures over program reporting and cash management requirements, increasing risk of report errors to awarding agencies and wrongly receiving monies Cluster Name: Workforce Innovation and Opportunity Act (WIOA) Cluster Assistance Listings number...
2025-102 The County did not develop internal control procedures over program reporting and cash management requirements, increasing risk of report errors to awarding agencies and wrongly receiving monies Cluster Name: Workforce Innovation and Opportunity Act (WIOA) Cluster Assistance Listings numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Award Numbers and years: IGA DI21-002286 July 1, 2024 through June 30, 2025 IGA DI23-002389 July 1, 2023 through June 28, 2028 Assistance Listings numbers and program name: 21.027 COVID-19—Coronavirus State and Local Fiscal Recovery Funds Award Numbers and years: 1505-0271 March 3, 2021 through December 31, 2024 CT-FM-22-149 October 1, 2024 through September 30, 2025 SLFRFP1962 January 5, 2023 through December 31, 2026 CTR069300 January 1, 2024 through December 30, 2026 GTAW-FM-23*123 October 3, 2022 through July 3, 2026 ACJC-VC-25-001A July 1, 2024 through December 31, 2024 Assistance Listings numbers and program name: 93.268 Immunization Cooperative Agreements Award numbers and years: CTR062571 July 1, 2022 through June 30, 2025 CTR059891 July 1, 2022 through June 30, 2027 Name of contact person: Art Cuaron, Director, Finance and Risk Management Anticipated completion date: June 30, 2027 The County recognizes the need to strengthen internal controls over federal reporting and cash management requirements. F&RM will complete the following actions to ensure compliance with 2 CFR Part 200: 1. Establish written internal control policies and procedures for federal program reporting. All federal financial reports will undergo an independently documented review before submission to ensure accuracy, allowability, and proper reporting periods. 2. Implement documentation standards requiring staff to retain supporting materials such as system reports, financial queries, screenshots, and reconciliations, in accordance with federal and County retention requirements. 3. Pima County has been working with each of its grant implementing entities to use Euna Grants calendaring and reminders to prompt the entities’ timely reporting activities. Grants Management and Innovation (GMI) Department sets the reminders schedule at the onset of the performance period. The reminders are then automatically emailed to the grants manager and the assigned accountant for each grant on a set schedule throughout the course of the grant. GMI and Finance – Grants will continue to work with grant implementing entities to use these reminders to trigger the necessary actions in a timely manner. Pima County was still in the process of institutionalizing this system during FY25. 4. Provide training for staff who prepare and review federal reports, focusing on reporting requirements, documentation standards, internal controls, and record retention. 5. Conduct periodic management oversight reviews to confirm that internal controls are followed and that reports are complete, accurate, and submitted on time. The County is also planning to implement the Workday Grants Module with an anticipated go-live of July 1, 2027. This solution will enhance our ability to manage the full fiscal lifecycle of grant awards and ensure compliance with federal reporting requirements. The Workday Grants Module is a native Workday solution, purpose-built to support the full fiscal grant lifecycle. The module supports the following financial grant objectives: • Grant setup and award and fiscal tracking • Cost allocation and allocability controls • Real-time grant financial reporting • Compliance with federal Uniform Guidance (2 CFR 200) • Integration with Workday Financial Management, Procurement and Human Capital Management (HCM) In addition, F&RM has submitted FY 2026/27 budget requests to fund three additional Accountant III positions in our Finance – Grants Division. These positions will expand our capacity to manage our grant portfolio and strengthen our reconciliation, billing and SEFA preparation processes. The contract for the Workday Grants Module is scheduled to go before the Board of Supervisors for approval in April. These new positions will be included in the County Administrator’s Recommended Budget and will be considered by the Board as part of the full budget adoption process in June.
AUDIT FINDINGS Finding Reference Number: 2025-001 Description of Finding: The District is required to submit semi-annual Performance (Technical) Reports where the reporting of grant expenditures must reconcile to the expenditures reported on SF-425 for the same reporting period. For the reporting pe...
AUDIT FINDINGS Finding Reference Number: 2025-001 Description of Finding: The District is required to submit semi-annual Performance (Technical) Reports where the reporting of grant expenditures must reconcile to the expenditures reported on SF-425 for the same reporting period. For the reporting period ended March 31, 2025, the District's CMC Performance Report Line Bk (Totals) agreed to SF-425 Line 1 Ob (Federal cash disbursements) rather than SF-425 Line 1 Oe (Federal share of expenditures). The Performance Report did not accurately present total expenditures for the CMC award for the period. This results in noncompliance with the program's reporting requirements. The Performance Report reported cash disbursement data instead of accrual-basis expenditure data. Statement of Concurrence or Nonconcurrence: Management acknowledges that due to an oversight of cash vs. accrual basis accounting, an immaterial misstatement not resulting in questioned costs or returned funds occurred in grant reporting. Corrective Action: To ensure the increased accuracy of future grant reporting, Management will implement a dual-review process for all future performance reporting. The grant accountant responsible for the financial Performance Report data will now complete a standardized quality assurance checklist before submission. This report will then be formally reviewed and cross-referenced against source data by a secondary finance administrator to verify the accuracy of reported metrics. The CMC (Technical) Performance Report in question has been adjusted to reflect the accurate expenditure values and resubmitted to the grantor. Name of Contact Person: Kim DiCaro, Chief Financial Officer Phone: (313)496-2532 Email: kdicaro1@wcccd.edu Projected Completion Date: The corrective action plan has been implemented; March 18, 2026
Develop and formally adopt a written procurement policy compliant with 2 CFR 200.317 - 200.327 Train all staff involved in procurement to ensure consistent understanding and proper implementation Perform periodic reviews and updates of the procurement policy to maintain compliance with evolving fede...
Develop and formally adopt a written procurement policy compliant with 2 CFR 200.317 - 200.327 Train all staff involved in procurement to ensure consistent understanding and proper implementation Perform periodic reviews and updates of the procurement policy to maintain compliance with evolving federal requirements.
Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct ...
Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct Loan, and Federal Family Education Loan (“FFEL”) programs. The University concurs with the finding and recognizes the importance of accurate and timely reporting to the National Student Loan Data System (“NSLDS”) in accordance with federal requirements (OMB No. 1845-0035). The University is committed to strengthening internal controls, enhancing operational procedures, and ensuring full compliance with all enrollment reporting requirements. II. Criteria Institutions participating in federal student aid programs are required to: • Report accurate enrollment information through NSLDS, including enrollment status and program-level data elements. • Ensure that all significant data elements—including enrollment status, program begin date, and enrollment effective date—are accurate as of the reporting date. • Submit enrollment reporting updates at least every 60 days (bi-monthly). • Maintain adequate internal controls to ensure data integrity and compliance with federal regulations. III. Condition The audit identified errors in enrollment reporting for a sample of 25 students, including: • 2 instances of incorrect program enrollment effective date reporting These errors were attributed to administrative oversight and insufficient internal controls governing enrollment reporting processes. IV. Cause Analysis The University has identified the following contributing factors: • Insufficient internal controls and review mechanisms over enrollment status updates • Limited system automation and alert capabilities for tracking status changes • Inadequate staffing resources to manage reporting timelines and data verification • Lack of formalized cross-functional coordination between the Office of the Registrar and reporting entities • Absence of an independent monitoring function to ensure compliance consistency V. Corrective Actions and Implementation Plan The University will implement the following corrective actions to address the identified deficiencies: 1. Establishment of Internal Audit Function • The University will establish a formal Internal Audit function by the start of the next academic year. • This function will have broad authority to oversee compliance, enforce corrective actions, and evaluate internal controls across all relevant departments. • Internal Audit will lead ongoing reviews of enrollment reporting processes and ensure accountability. 2. Process Review and Cross-Functional Collaboration • Internal Audit will coordinate a comprehensive review of enrollment reporting processes involving the Office of the Registrar and the National Student Loan Clearinghouse. • This review will include a structured assessment of strengths, weaknesses, opportunities, and risks (SWOT analysis). • Standard operating procedures (SOPs) will be updated and formally documented. 3. Staffing and Resource Enhancements • The University will enhance staffing within the Office of the Registrar to support enrollment reporting functions. • Additional technological tools and system capabilities will be implemented to provide automated alerts, status tracking, and exception reporting. 4. Implementation of Monitoring and Control Systems • A robust monitoring system will be deployed to: o Track student enrollment status changes in real time o Generate alerts for discrepancies or missing data o Ensure timely submission of required updates to NSLDS • Data validation checkpoints will be integrated prior to submission to ensure accuracy. 5. Strengthening Reporting Protocols • Interim control measures will include the submission of transfer student status reports on a semester basis until full remediation is achieved. • All enrollment updates will undergo a secondary review and certification prior to submission. • A compliance calendar will be implemented to ensure adherence to the 60-day reporting requirement. 6. Training and Accountability Measures • Mandatory training sessions will be conducted for all personnel involved in enrollment reporting. • Training will focus on federal requirements, data accuracy standards, and system utilization. • Performance expectations and accountability metrics will be clearly defined and monitored. VI. Timeline for Implementation • Immediate (0–90 Days): o Initiate staffing enhancements o Implement interim review and validation procedures o Conduct training sessions • Short-Term (90–120 Days): o Deploy monitoring and alert systems o Formalize SOPs and compliance calendar o Begin enhanced reporting protocols • Long-Term (By Start of Next Academic Year): o Fully establish Internal Audit function o Complete comprehensive process review and continuous monitoring framework VII. Monitoring and Ongoing Compliance The Internal Audit function will conduct periodic reviews and report findings for executive leadership. Continuous monitoring will ensure that corrective actions remain effective and that compliance with federal regulations is sustained. VIII. Conclusion Through the implementation of these corrective measures, the University will address the deficiencies identified in Finding 2025-001 and significantly strengthen its internal control environment. These actions will ensure accurate and timely enrollment reporting, uphold the integrity of federal student aid programs, and reinforce the University’s commitment to regulatory compliance and operational excellence. Anticipated Completion Date: September 1, 2026
Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct ...
Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct Loan, and Federal Family Education Loan (“FFEL”) programs. The University concurs with the finding and recognizes the importance of accurate and timely reporting to the National Student Loan Data System (“NSLDS”) in accordance with federal requirements (OMB No. 1845-0035). The University is committed to strengthening internal controls, enhancing operational procedures, and ensuring full compliance with all enrollment reporting requirements. II. Criteria Institutions participating in federal student aid programs are required to: • Report accurate enrollment information through NSLDS, including enrollment status and program-level data elements. • Ensure that all significant data elements—including enrollment status, program begin date, and enrollment effective date—are accurate as of the reporting date. • Submit enrollment reporting updates at least every 60 days (bi-monthly). • Maintain adequate internal controls to ensure data integrity and compliance with federal regulations. III. Condition The audit identified errors in enrollment reporting for a sample of 25 students, including: • 2 instances of incorrect program enrollment effective date reporting These errors were attributed to administrative oversight and insufficient internal controls governing enrollment reporting processes. IV. Cause Analysis The University has identified the following contributing factors: • Insufficient internal controls and review mechanisms over enrollment status updates • Limited system automation and alert capabilities for tracking status changes • Inadequate staffing resources to manage reporting timelines and data verification • Lack of formalized cross-functional coordination between the Office of the Registrar and reporting entities • Absence of an independent monitoring function to ensure compliance consistency V. Corrective Actions and Implementation Plan The University will implement the following corrective actions to address the identified deficiencies: 1. Establishment of Internal Audit Function • The University will establish a formal Internal Audit function by the start of the next academic year. • This function will have broad authority to oversee compliance, enforce corrective actions, and evaluate internal controls across all relevant departments. • Internal Audit will lead ongoing reviews of enrollment reporting processes and ensure accountability. 2. Process Review and Cross-Functional Collaboration • Internal Audit will coordinate a comprehensive review of enrollment reporting processes involving the Office of the Registrar and the National Student Loan Clearinghouse. • This review will include a structured assessment of strengths, weaknesses, opportunities, and risks (SWOT analysis). • Standard operating procedures (SOPs) will be updated and formally documented. 3. Staffing and Resource Enhancements • The University will enhance staffing within the Office of the Registrar to support enrollment reporting functions. • Additional technological tools and system capabilities will be implemented to provide automated alerts, status tracking, and exception reporting. 4. Implementation of Monitoring and Control Systems • A robust monitoring system will be deployed to: o Track student enrollment status changes in real time o Generate alerts for discrepancies or missing data o Ensure timely submission of required updates to NSLDS • Data validation checkpoints will be integrated prior to submission to ensure accuracy. 5. Strengthening Reporting Protocols • Interim control measures will include the submission of transfer student status reports on a semester basis until full remediation is achieved. • All enrollment updates will undergo a secondary review and certification prior to submission. • A compliance calendar will be implemented to ensure adherence to the 60-day reporting requirement. 6. Training and Accountability Measures • Mandatory training sessions will be conducted for all personnel involved in enrollment reporting. • Training will focus on federal requirements, data accuracy standards, and system utilization. • Performance expectations and accountability metrics will be clearly defined and monitored. VI. Timeline for Implementation • Immediate (0–90 Days): o Initiate staffing enhancements o Implement interim review and validation procedures o Conduct training sessions • Short-Term (90–120 Days): o Deploy monitoring and alert systems o Formalize SOPs and compliance calendar o Begin enhanced reporting protocols • Long-Term (By Start of Next Academic Year): o Fully establish Internal Audit function o Complete comprehensive process review and continuous monitoring framework VII. Monitoring and Ongoing Compliance The Internal Audit function will conduct periodic reviews and report findings for executive leadership. Continuous monitoring will ensure that corrective actions remain effective and that compliance with federal regulations is sustained. VIII. Conclusion Through the implementation of these corrective measures, the University will address the deficiencies identified in Finding 2025-001 and significantly strengthen its internal control environment. These actions will ensure accurate and timely enrollment reporting, uphold the integrity of federal student aid programs, and reinforce the University’s commitment to regulatory compliance and operational excellence. Anticipated Completion Date: September 1, 2026
Finding 2025-003 – Reporting – Special Reports for Federal Funding Accountability and Transparency Act (“FFATA”) Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-003 regarding noncompliance with reporting requirements under the Federal Funding Accountabi...
Finding 2025-003 – Reporting – Special Reports for Federal Funding Accountability and Transparency Act (“FFATA”) Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-003 regarding noncompliance with reporting requirements under the Federal Funding Accountability and Transparency Act. Specifically, the University did not submit a first-tier subaward agreement/amendment/modification within the required timeframe to the System for Award Management (SAM.gov). The University concurs with the findings and is committed to strengthening its internal controls, procedures, and oversight mechanisms to ensure full compliance with all FFATA reporting requirements moving forward. II. Criteria Under FFATA requirements: • Recipients of federal grants or cooperative agreements must report first-tier subawards of $30,000 or more to SAM.gov. • Reporting must be completed timely and accurately in accordance with federal guidelines. • Institutions must maintain sufficient internal controls to ensure that all reportable subawards are identified, tracked, and submitted within required deadlines. III. Condition The audit determined that a subaward agreement, amendment, or modification meeting FFATA reporting thresholds was not submitted within the required timeframe. This reflects a lapse in the University’s internal processes governing subrecipient monitoring and reporting compliance. IV. Root Cause Analysis The University has identified the following contributing factors: • Inadequate tracking mechanisms for subaward reporting deadlines • Insufficient coordination between Grants Administration and responsible program personnel • Lack of automated alerts and centralized monitoring systems • Gaps in internal review and approval workflows prior to submission • Limited oversight to ensure timely compliance with FFATA requirements V. Corrective Actions and Implementation Plan The University will implement the following corrective measures effective immediately: 1. Internal Audit Oversight and Governance • The Internal Audit function will assume leadership responsibility for overseeing FFATA compliance and subrecipient reporting processes. • Quarterly compliance reports will be prepared and submitted directly to the Vice President and Chief Finance Officer until sustained compliance is achieved. • Internal Audit will conduct periodic reviews and testing of subaward reporting to ensure adherence to federal requirements. 2. Enhanced Tracking and Monitoring Systems • A centralized tracking system will be implemented to monitor all subawards, including thresholds, reporting deadlines, and submission status. • Automated alerts and reminders will be established to notify responsible personnel of upcoming reporting deadlines. 3. Strengthening Policies and Procedures • Standard Operating Procedures (“SOPs”) for FFATA reporting will be updated and formally documented. • Procedures will clearly define roles, responsibilities, timelines, and escalation protocols for noncompliance. • A compliance checklist will be required prior to execution and modification of all subaward agreements. 4. Improved Interdepartmental Coordination • Formal communication protocols will be established between Grants Administration, Principal Investigators, and Finance to ensure timely identification and reporting of subawards. • Designated compliance liaisons will be assigned to ensure accountability across departments. 5. Training and Capacity Building • Mandatory training will be conducted for all staff involved in grants management and subrecipient oversight. • Training will focus on FFATA requirements, reporting timelines, system usage, and compliance expectations. 6. Pre-Submission Review and Quality Assurance • A secondary review process will be implemented prior to submission to SAM.gov to ensure accuracy and completeness. • Documentation supporting all submissions will be retained in a centralized repository for audit and compliance purposes. VI. Timeline for Implementation • Immediate: o Initiate Internal Audit oversight o Implement interim tracking and reporting processes o Begin staff training • Short-Term: o Deploy centralized tracking system and automated alerts o Finalize and implement updated SOPs o Begin quarterly reporting to the Vice President and Chief Finance Officer • Long-Term (Ongoing): o Conduct continuous monitoring and compliance reviews o Maintain quarterly reporting until full and sustained compliance is achieved VII. Monitoring and Ongoing Compliance The Internal Audit function will provide ongoing monitoring and validation of FFATA reporting compliance. Quarterly reports will include status updates, identified issues, corrective actions, and recommendations for continuous improvement. VIII. Conclusion The University is committed to addressing the deficiencies identified in Finding 2025-003 through enhanced oversight, improved processes, and strengthened internal controls. These actions will ensure timely and accurate subaward reporting, uphold compliance with FFATA requirements, and reinforce the University’s commitment to transparency and accountability in federal grant management. Anticipated Completion Date: September 1, 2026
Finding: The company did not implement the HUD approved rent adjustments for October 2024 in a timely fashion. Corrective Actions Taken: Management subsequently made the retroactive adjustments to HUD which have been approved by and paid to HUD. In addition, management has implemented a formal revie...
Finding: The company did not implement the HUD approved rent adjustments for October 2024 in a timely fashion. Corrective Actions Taken: Management subsequently made the retroactive adjustments to HUD which have been approved by and paid to HUD. In addition, management has implemented a formal review and corss-verification process to ensure that rent adjustments are completed accurately and in a timely manner.
Cochise County Corrective Action Plan Year ended June 30, 2025 2025-101 Assistance Listings number and name: 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number and years: CTR067930, October 1, 2023 through September 30, 2028 Federal agency: U.S. Departmen...
Cochise County Corrective Action Plan Year ended June 30, 2025 2025-101 Assistance Listings number and name: 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number and years: CTR067930, October 1, 2023 through September 30, 2028 Federal agency: U.S. Department of Agriculture Pass-through grantor: Arizona Department of Health Services Compliance requirement: Eligibility Questioned costs: Unknown The County did not perform eligibility certification requirements, resulting in an increased risk of program participants receiving benefits they are not eligible to receive Contact: Barbara Lang Completion date: March 2026 Corrective Action: Cochise County WIC leadership and staff are committed to full adherence with WIC policy and will continue to implement training, monitoring, and communication to ensure compliance with federal and state regulation. This audit timeframe produced findings primarily related to issues that have already been corrected through the departure of staff that contributed to the findings (to include the previous Directors), hiring of new staff with a more thorough and comprehensive training plan implemented, and staff effort to retroactively collect all required signatures at subsequent appointments to ensure all WIC clients have current signatures and understanding of Rights & Obligations and Consents for their certification period. We recognize that these new processes were not put into plan until June 2025, due to the timing of the previous audit, and therefore did not reflect on the July 1, 2024 – June 30, 2025 audit period. In addition to the above resolved issues, a new WIC director was hired in September 2025 and new policies and procedures were immediately developed and put into place. These new policies and procedures that serve as our already implemented corrective action plan are as follows: Staff Training a. All staff are required to complete the full ADHS WIC-sponsored live cohort training courses upon hire, and every 3 years of their employment to ensure competencies are maintained over time. b. All staff complete their annual Civil Rights, Conflict of Interest, and Confidentiality upon hire and annually. Last annual training was completed Fall 2025. c. A staff dedicated as Training Coordinator monitors training logs and ensure all training requirements are met, with additional oversight by the WIC Director and the ADHS WIC State office. d. In-person staff meetings are held monthly, with a significant portion of time dedicated to staff training on programmatic expectations to ensure all staff obtain the same information so that tasks are carried out in a standardized method. e. Weekly team huddles to review any timely findings or discuss issues as a group. f. Weekly 1:1’s with each staff to discuss areas where the employee may need additional training or to discuss any deficiencies the WIC manager has noticed, (i.e. note-taking/documentation, single income verifications, chart review findings, etc.). Separation of Duties g. Cert List for Audits report run every 2 weeks for each clinic/staff person to review adherence to Separation of Duties. i. Follow up with certain percentage of clients per policy to assess how the certification went and verify client information. ii. Follow up with staff if any issues are identified. h. Staff have been training on during staff meetings in July 2025, August 2025, October 2025, and during new employee training on how to properly use the HANDS system to ensure the system accurately records who completed the 2nd income verification. i. Revision of Separation of Duties policy and implementation of new “protected time” procedure to ensure there is a staff person available at almost all times of day to complete the 2nd IV. *Since approval of this policy the ADHS WIC state office on 1/5/2026 and implementation of this policy/procedure, the Cert List for Audit report of single-income verifications has decreased substantially (from 60 in 2 weeks, to 5), all with documented reasons why 2nd IV was unable to be obtained during certification appointment and notes verifying 2nd IV was completed on another date. Rights and Obligations and Consent Forms a. All staff received a refresher training on 8/26/25, will be retrained annually, and are regularly reminded to obtain both required signatures at certification b. If staff are unable to obtain digital signatures due to tech issues, they are required to obtain e-document signatures via the clients email, or written signatures the staff then scans into the client file c. Chart reviews and staff observations are completed on a monthly-bimonthly basis to ensure ongoing staff compliance with policy and procedure
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