Corrective Action Plans

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Finding 2025-001: Suspension and Debarment Condition: The Sponsoring Organization did not consistently document the verification that new Child and Adult Care Food Program (CACFP) centers or Family Child Care (FCC) providers were not suspended or debarred prior to enrollment. View of Responsible Off...
Finding 2025-001: Suspension and Debarment Condition: The Sponsoring Organization did not consistently document the verification that new Child and Adult Care Food Program (CACFP) centers or Family Child Care (FCC) providers were not suspended or debarred prior to enrollment. View of Responsible Officials: 4C agrees with the audit finding. Corrective Action Plan: 4C will implement a control process within the onboarding process. The onboarding check list will have sign offs for the manager and strategic director over the program. Responsible Party: Pagie Runion, Strategic Director of Business Services Anticipated Completion Date: June 30, 2026
The Workforce Development Department (GuilfordWorks) experienced turnover in program service level staffing during FY 2025 along with certain periods of vacancies. Additional training related to federal grant accounting, particularly the reporting requirements for the Department of Labor, will be co...
The Workforce Development Department (GuilfordWorks) experienced turnover in program service level staffing during FY 2025 along with certain periods of vacancies. Additional training related to federal grant accounting, particularly the reporting requirements for the Department of Labor, will be conducted with program staff. Backup program staff are now in place in case of primary staff absences. Finance Department staff will also hold periodic discussions with GuilfordWorks staff to ensure that reporting deadlines are consistently being met timely.
The District is correcting the eligibility status of student participants and is providing training to those that determine the eligibility status to ensure proper eligibility determination in the future.
The District is correcting the eligibility status of student participants and is providing training to those that determine the eligibility status to ensure proper eligibility determination in the future.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
Continued understanding is still needed from prior fiscal years. We have improved but more leanring and improvement is needed. We will continue to review account numbers throughout the year to better understand what journal entries need to be made.
Continued understanding is still needed from prior fiscal years. We have improved but more leanring and improvement is needed. We will continue to review account numbers throughout the year to better understand what journal entries need to be made.
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2025-003 also applies to State award findings. Section IV - State Award Findings and Questioned Costs Section III - Federal Aw...
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2025-003 also applies to State award findings. Section IV - State Award Findings and Questioned Costs Section III - Federal Award Findings and Questioned Costs Jessica Wall, Human Services Director and Marcy Mays, Assistant Human Services Director Training to include technical assistance related to all Single County Audit Findings from the most recent audit. This training included a powerpoint presentation that covered income calculations, resources, self-employment and how to document each of these. During this training, we covered toggling into each determination to check for validity and made it a requirement that each caseworker calculate income outside of the system, upload their own calcuations into NCFast and verify that the outside calculation matches that in the system. Operational Support Representative visited the agency to provide training on self-employment, unemployment, passalong, SSI cases and passalong. Internally, we have developed second-party spreadsheets per worker to be able to better track individual performance and training needs. Internal Training completed on 09/17/25. Operational Support Training was provided on 10/22/25. Supervisors will provide at least monthly training on any new policy updates or second-party findings. 131
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Co...
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Compliance Officer will be designated to oversee policy implementation and annual updates. Standard operating procedures will be issued for relevant departments, and mandatory staff training will be conducted. These actions will be completed by March 31, 2026, with ongoing monitoring through quarterly compliance meetings. Anticipated Completion Date: March 31, 2026
2025-003 – Significant Deficiency and Noncompliance – Federal Equipment Corrective Action Plan: The City will implement a centralized Federal Equipment Register capturing all required data elements under 2 CFR §200.313(d) and assign responsibility to the Logistics Officers of the Fire Department, Po...
2025-003 – Significant Deficiency and Noncompliance – Federal Equipment Corrective Action Plan: The City will implement a centralized Federal Equipment Register capturing all required data elements under 2 CFR §200.313(d) and assign responsibility to the Logistics Officers of the Fire Department, Police Department, and Department of Public Works, with oversight by Finance. A full physical inventory of federally funded equipment will be completed and reconciled by March 31, 2026, and biennial inventory procedures will be established. Staff will be trained on equipment management requirements, and documentation will be retained to ensure compliance. Anticipated Completion Date: March 31, 2026
Policy Clarification: Procedures have been revised to explicitly require the use of calendar days for the 45-day deadline. Process Controls: A standardized checklist and calendar alerts are now in place to track withdrawal dates and refund deadlines. Monitoring: Monthly self-reviews of all R2T4 file...
Policy Clarification: Procedures have been revised to explicitly require the use of calendar days for the 45-day deadline. Process Controls: A standardized checklist and calendar alerts are now in place to track withdrawal dates and refund deadlines. Monitoring: Monthly self-reviews of all R2T4 files will be conducted by the Director of Academic Services to ensure timely processing.
Management concurs with the auditor's finding. The noncompliance resulted from a communication breakdown between the College and its third-party financial aid processing company, FAME, Inc. When William R. Moore College of Technology (the College) was placed under Heightened Cash Monitoring 1 (HCMl)...
Management concurs with the auditor's finding. The noncompliance resulted from a communication breakdown between the College and its third-party financial aid processing company, FAME, Inc. When William R. Moore College of Technology (the College) was placed under Heightened Cash Monitoring 1 (HCMl), staff did not immediately notify FAME of the status change. Had FAME been informed, the company would have updated the system configuration to restrict drawdowns until all credit balances were determined and paid. Although this was a communication lapse, the College did follow through on all U.S. Department of Educationdirectives related to financialresponsibility and provisional certification. Specifically, the College obtained and maintained the required Irrevocable Standby Letter of Credit (LOC) each time it was instructed to do so and amended the LOC amount in subsequent years as required by the Department. To correct this issue and ensure full compliance with federal cash-management regulations, the College has implemented the following actions: Notification Protocol and Financial Protection Requirements Before notifying FAME of any change in payment method (placement under or release from HCMl), the College must verify compliance with the Department of Education's Provisional Certification Alternative requirements under 34 C.F.R. § 668.l?S{f). The institution must submit an Irrevocable Standby Letter of Credit (LOC) or cash surety equal to 10% of the most recently completed fiscal year's Title IV funding. The College has complied with this requirement by obtaining and maintaining the LOC as directed and by amending the LOC amount ea'ch time the Department requested an updated financial protection amount. The LOC ensures funds are available to make refunds, provide teach-out facilities, and meet institutional obligations should the College close or terminate classes prematurely. The CFO confirms acceptance of the LOC by the Department before formally notifying FAME of any payment method change (HCMl, HCM2, or release). System Configuration Controls Once notified, FAME has confirmed that the system includes a compliance flag preventing drawdowns prior to disbursement while the College operates under HCMl. This configuration ensures that all Title IV reimbursements occur only after funds have been properly disbursed to students. Staff Training and Awareness Internal financial aid and accounting staff will participate in refresher training with FAME in Spring 2026. The training will cover: Title IV cash-management rules Communication and notification protocols Credit-balance determination and documentation standards Documentation and Oversight A written Title IV Reimbursement Checklist and Approval Workflow has been incorporated into the College's HCMl reimbursement process. The Financial Aid Counselor verifies completion of all disbursement and documentation steps prior to reimbursement. The CFO provides final authorization for each GS drawdown. 5. Monitoring and Continuous Improvement The College conducts quarterly internal reviews of Title IV drawdowns, reconciliations, and reimbursement documentation to confirm ongoing compliance. All findings are shared with FAME to maintain consistent alignment between systems and audit documentation. Anticipated Completion Date: All corrective actions were implemented by October 31, 2025; additional staff training is scheduled for Spring 2026. Status: As of June 30, 2025, the College is no longer operating under Heightened Cash Monitoring 1 (HCMl) and has returned to the standard payment method. However, corrective actions have been implemented; continued monitoring and staff training are in progress. Views of Responsible Official Management agrees with the finding. The noncompliance occurred due to a communication lapse between the College and its third-party processor, FAME, regarding requirements under the Heightened Cash Monitoring 1 (HCMl) payment method. In response, the College has updated its Title IV cash-management policies and procedures to ensure full compliance with federal regulations and the terms of its Provisional Certification Alternative under 34 C.F.R. § 668.175(f). Corrective actions include the submission and amendment of the Irrevocable Standby Letter of Credit, implementation of enhanced notification and verification procedures before alerting FAME of any payment-method changes, and establishment of quarterly internal reviews to confirm ongoing compliance with cash management and financial protection requirements.
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient ...
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Beginning in February 2025, Bailey-Boushay House Administrative staff send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor forwards a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor discusses the status of these updates during meetings with care manager/social worker. Notes are made on the caseload list to document the discussion of status. The Clinical Supervisor sends a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note is provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations are retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Completion: February 2025
REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria wi...
REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders are sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The Finance Manager reviews the timecard allocations and populates the hours charged to the grant per the timecard on to the salary allocation spreadsheet. The salary allocation spreadsheet is utilized in completing the reimbursement request. The timecards and the allocation spreadsheet are included in the reimbursement request. Beginning in January 2026, the salary allocation spreadsheet and timecards will be reviewed and signed off by the Director of Outpatient Programs as part of the reimbursement request approval process. Additionally, timecard approval compliance for prior periods will be reviewed during Bailey-Boushay weekly leadership meetings. Person Responsible: Rob Hays, Executive Director – Bailey-Boushay House Expected Completion: January 2026
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: A Federal Direct Loan exit interview was not completed by, nor were instructions sent t...
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: A Federal Direct Loan exit interview was not completed by, nor were instructions sent to, students on how to complete an exit interview when the students graduated from the College or dropped below a halftime enrollment status. This was applicable for two of the nine students selected for testing that received Federal Direct Loan funds. Corrective Action Plan: Federal Direct Loan exit interview information was sent to one of the students in question in August 2025 and the second student in question in September 2025. Procedures will be improved to ensure Federal Direct Loan exit interviews are completed or information is sent to students when they cease enrollment at the College. Anticipated Completion Date: The corrective action was completed in August 2025 and September 2025. Contact Person: Stephanie Dickerson, Registrar/Financial Aid
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: The incorrect withdrawal date was reported to the National Student Loan Database System...
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: The incorrect withdrawal date was reported to the National Student Loan Database System (“NSLDS”) for four of the nine students selected for testing that received Federal Direct Student Loans. Corrective Action Plan: Management agrees with the auditors’ finding and their recommendation. The Financial Aid Director updated the enrollment status for the students in question in December 2025. Procedures will be improved to ensure that a student’s enrollment status is updated timely and with the correct date of the change. Anticipated Completion Date: The corrective action was completed in December 2025. Contact Person: Stephanie Dickerson, Registrar/Financial Aid 910-323-5614
No. 2025-001 Subject: Allowable Costs and Activities ‐ Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Byron Jones, CFO Phone Number: (480) 270-5438 Anticipated Completion Date: June 30, 2026 Corrective Action: We will strengthen internal co...
No. 2025-001 Subject: Allowable Costs and Activities ‐ Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Byron Jones, CFO Phone Number: (480) 270-5438 Anticipated Completion Date: June 30, 2026 Corrective Action: We will strengthen internal controls over employee time coding by implementing enhanced review procedures to ensure only allowable Child Nutrition activities are charged to the grant. Supervisors and the accounting team will review all payroll coding charged to the Child Nutrition Cluster to verify that the employee’s position and duties align with approved grant activities. These improved internal procedures will provide proper compliance over allowable costs. We will also conduct an annual audit of all grant-funded employee positions at the start of each school year, reviewed by the grants team, HR, and accounting, to verify the accuracy of all employee costing allocations to federal grants and to ensure any miscoding errors are identified and corrected in a timely manner.
Name of Contact Person: Mr. Mitch Nanney, Superintendent. Recommendation: We recommend the District verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000 and to keep all supporti...
Name of Contact Person: Mr. Mitch Nanney, Superintendent. Recommendation: We recommend the District verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000 and to keep all supporting documentation of the verification of the vendor's status. Corrective Action: We will verify all vendor's status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000 and keep all supporting documentation. Proposed Completion Date: Immediately.
Medicare Rural Hospital Flexibility Program Evaluation-Cooperative Agreement (Rural Health Cooperative Agreement) Federal Assistance Listing #93.241 Recommendation: The Organization should ensure they follow their policy to check for suspension and debarment prior to entering into the contract. Expl...
Medicare Rural Hospital Flexibility Program Evaluation-Cooperative Agreement (Rural Health Cooperative Agreement) Federal Assistance Listing #93.241 Recommendation: The Organization should ensure they follow their policy to check for suspension and debarment prior to entering into the contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure they follow their suspension and debarment policy moving forward and documentation is retained. In addition, contracting and suspension and debarment policies and procedures are being updated by the Organization to further strengthen compliance with all requirements of Title 2 U.S. Code of Federal Regulations Part 200. Name(s) of the contact person(s) responsible for corrective action: Dan Herstad, Controller Planned completion date for corrective action plan: 12/31/2025
Name of Responsible Individual: Matt Cooper, Student Financial Services Corrective Action: To strengthen compliance and ensure the accuracy of student aid eligibility determinations, we will enhance Liberty’s quality control (QC) measures within the federal verification process. Our primary goal is ...
Name of Responsible Individual: Matt Cooper, Student Financial Services Corrective Action: To strengthen compliance and ensure the accuracy of student aid eligibility determinations, we will enhance Liberty’s quality control (QC) measures within the federal verification process. Our primary goal is to minimize errors, improve consistency, and ensure all Financial Aid verification activities align with federal regulations and institutional policy. We will begin by implementing a more targeted QC process aimed at validating records of students who submitted subsequent tax documents. We will increase our verification QC selections of this particular population from 35% (current) to 60% (future) to verify data accuracy, documentation completeness, and adherence to ED’s Application and Verification Guide (AVG). Findings from these reviews will be used to identify training needs and process improvements. Staff training will be expanded to focus on federal verification requirements, common error trends, and documentation standards. Refresher trainings will be held with the entire verification processing team, and supplemental individual coaching will be provided on a monthly basis to address any specific issues identified through QC. We will also create reporting to ensure the percentage of reviews mentioned above is maintained by our QC workflow. Regular data analysis will help identify any systemic issues early, allowing for corrective actions to mitigate any compliance issues. By reinforcing staff training, system monitoring, and increased reviews, we will ensure that our federal verification process remains accurate, compliant, and student-centered. Anticipated Completion Date: February 2026
Name of Responsible Individual: Jason Byrd, University Registrar Corrective Action: Liberty University acknowledges that its FY25 single audit identified instances where students’ enrollment reporting was not updated in a timely manner in accordance with U.S. Department of Education (ED) requirement...
Name of Responsible Individual: Jason Byrd, University Registrar Corrective Action: Liberty University acknowledges that its FY25 single audit identified instances where students’ enrollment reporting was not updated in a timely manner in accordance with U.S. Department of Education (ED) requirements. Liberty has invested significant effort into ensuring its enrollment reporting process is handled compliantly and within alignment with ED’s best practices. Liberty’s Registrar’s Office created a new Director of Clearinghouse Reporting position in May 2024, who is responsible for monitoring Clearinghouse feeds and any associated error reports and works closely with Liberty’s Financial Aid and Information Technology (ADS) offices to ensure enrollment reporting compliance. Liberty has continued the work of developing a more comprehensive quality control (QC) process by reviewing the Clearinghouse Reject report in a timely manner, meeting on a monthly basis with internal stakeholders, and working more closely with Clearinghouse Representatives to identify scenarios where enrollment records are accurately reported to Clearinghouse but never sent on to NSLDS. Liberty University plans to provide Clearinghouse representatives with specific audit cases to identify gaps in enrollment reporting and increase accuracy of individual reviews. Liberty Internal QC Reporting: Liberty University will continue to work quality control and the Clearinghouse Reject report which has enabled the university to be more proactive in its compliance efforts. Additionally, Graduated Dates Prior to Term End, NSLDS MisMatches, NSLDS No Banner SSN, and the NSLDS Record Missing reports will continue to be worked in a timely manner. These reports have been helpful to identify more common/persistent errors/delays and provide an additional layer of quality control checks for Liberty’s enrollment reporting. Accountability Meetings Liberty began holding a series of bi-weekly “Enrollment Reporting Check-In” meetings with key stakeholders from Financial Aid, Registrar, and IT/ADS in February 2024, which are dedicated to discussing current and upcoming enrollment reporting submissions and errors, trends seen with SSCR errors, and brainstorming ways to ensure ongoing compliance. These meetings will continue with a focus on ways to improve reporting logic to prevent errors from occurring. While improvement efforts continue to be underway, Liberty believes these efforts are starting to bear fruit as evidenced by a 99.7% reduction in the number of repeat errors from FY24 to FY25. Finally, Liberty University uses a standard formula for its Program Lengths in order to ensure compliance with other requirements, however certain programs have unique program lengths which may not align with this standard formula for Enrollment Reporting purposes. The Financial Aid Office will work with Registrar and the Provost’s Office, to evaluate any programs which fall outside the standard formula and adjust the published program dates as necessary. Moving forward Liberty will continue to hold monthly meetings with key stakeholders to discuss any enrollment reporting errors and ensure best practices are implemented to ensure ongoing and timely accuracy. The University’s Registrar’s Office will also continue to review the QC reports in an appropriate manner, as well as evaluate the processes for withdrawal/graduated student files. Liberty will continue to review and implement updates as necessary to maintain enrollment reporting compliance and believes these new processes will allow us to be compliant in subsequent years. Anticipated Completion Date: May 2026
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