Corrective Action Plans

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Institutional Response The institution concurs with the auditor’s findings and affirms that this was an isolated occurrence. Due to an administrative error, the affected student enrollment reflected a combination of graduate and undergraduate courses. While the withdrawal process was fully executed ...
Institutional Response The institution concurs with the auditor’s findings and affirms that this was an isolated occurrence. Due to an administrative error, the affected student enrollment reflected a combination of graduate and undergraduate courses. While the withdrawal process was fully executed for the undergraduate courses, the graduate course remained active in the student information system, preventing the transaction from being recorded as a complete withdrawal. As part of the institution’s internal control and monitoring procedures, the discrepancy was detected and promptly corrected. A Return of Title IV (R2T4) calculation was performed in accordance with federal regulations. The institution remains committed to continuous improvement and regulatory compliance. Additional staff training and process reviews have been implemented to strengthen internal controls and prevent similar occurrences in the future. Corrective Action Plan To strengthen compliance and prevent recurrence, the Miami campus has implemented the Degree Audit functionality in Ellucian Colleague. This enhancement ensures that all course enrollments, term dates, and institutional charges are accurately reflected in the system, allowing the R2T4 process to operate with complete and consistent data. The R2T4 reports are already in place, and staff training, along with improved communication among Student Services and Finance offices, will reinforce timely and accurate processing. Implementation of the Degree Audit at the San Juan campus will follow the completion of a curricular change currently under development by the Academic Department. In the meantime, the San Juan campus continues to apply stricter procedures, such as requiring program director authorization before students enroll in courses outside their academic program. Anticipated completion date Immediately Name(s) of the Contact Person(s) Responsible for the Corrective Action Plan Mrs. Ileana Santiago, Controller Dr. Antonio Llorens, CIO
Institutional Response The institutions agree with the auditor. This was an isolated case of the roster. The institution concurs with the auditor’s finding. We acknowledge the delay in issuing one refund beyond the required 14-day timeframe. Although this was an isolated occurrence, the University i...
Institutional Response The institutions agree with the auditor. This was an isolated case of the roster. The institution concurs with the auditor’s finding. We acknowledge the delay in issuing one refund beyond the required 14-day timeframe. Although this was an isolated occurrence, the University is committed to strengthening its internal controls and leveraging technology to prevent recurrence and ensure full compliance with federal regulations. Corrective Action Plan The institution is enhancing automation, monitoring, and accountability to ensure compliance with the 14-day refund requirement. Using Ellucian Colleague’s ODS/Informer, new reports will track Title IV credit balances and flag accounts exceeding 10 days without a refund as a preventive control. These reports will run weekly or more frequently to maintain proactive oversight. A dedicated staff member in the Student Accounts Office will be specifically assigned to process refunds within the required timeframe, ensuring clear accountability and preventing delays. The Finance organizational chart and staff assignment are under review, with the final assignment to be completed by December 1, and the reports are expected to be running by November 3. Anticipated completion date December 1, 2025 Name(s) of the Contact Person(s) Responsible for the Corrective Action Plan Mrs. Ileana Santiago, Controller Dr. Antonio Llorens, CIO
The financial aid office is under new leadership as of January 1, 2025. During 2025, department leadership began its review of departmental policies and procedures, focusing on remediating compliance weaknesses within the department while moving toward best practice in federal and state aid delivery...
The financial aid office is under new leadership as of January 1, 2025. During 2025, department leadership began its review of departmental policies and procedures, focusing on remediating compliance weaknesses within the department while moving toward best practice in federal and state aid delivery. Department leadership has put structures in place at multiple points of potential failure to prevent inaccurate aid calculations. These structures include new policy and procedure documentation, enhanced optimization in the Banner system, staff training in multiple modalities including intradepartmental training, asynchronous independent training, off-site training, and a monthly reconciliation program with AVC’s fiscal office. We have also begun a system of cross training to ensure that expertise persists within the department during times of staffing changes, extended leaves of absence, and vacancies.
Finding 2025-001: During the year ended September 30, 2025, the Company loaned funds totaling $10,850 to two other Communities under common management and affiliated with the Sole Member of the Company to help fund operating shortfalls of the other Communities. Comments on the Finding and Each Recom...
Finding 2025-001: During the year ended September 30, 2025, the Company loaned funds totaling $10,850 to two other Communities under common management and affiliated with the Sole Member of the Company to help fund operating shortfalls of the other Communities. Comments on the Finding and Each Recommendation: Management and/or the Sole Member should reimburse the Company for the funds that were loaned to the two other Communities. If there are further operating shortfalls in the future, these should be funded by Management and/or the Sole Member and not borrowed from other Communities. Action(s) taken or planned on the finding: Management concurs with the finding and agrees with the recommendation. On November 7, 2025, Management deposited $10,850 into the Community's operating account. No further action is required.
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $5,119 from the operating account to the reserve for replacements account when there is cash avail...
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $5,119 from the operating account to the reserve for replacements account when there is cash available. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management deposited $5,119 into the replacement reserve on November 18, 2025, and will continue to make monthly deposits to the reserve as cash flow allows to ensure compliance.
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $3,535 from the operating account to the reserve for replacements account when there is cash avail...
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $3,535 from the operating account to the reserve for replacements account when there is cash available. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management deposited $3,535 into the replacement reserve on November 7, 2025, and will continue to make monthly deposits to the reserve as cash flow allows to ensure compliance.
Lack of Review Documentation (Significant Deficiency) Condition: Four participants were selected for eligibility test work for the Upward Bound Math and Science (UBMS) program. All four of these participants applications did not have any indication that they were reviewed or approved by the appropri...
Lack of Review Documentation (Significant Deficiency) Condition: Four participants were selected for eligibility test work for the Upward Bound Math and Science (UBMS) program. All four of these participants applications did not have any indication that they were reviewed or approved by the appropriate program director before receiving services from the program. Criteria: Based on the clients controls over TRIO eligibility, the program directors obtain various documents from the participant in order to make a determination of eligibility prior to the participant receiving services from the program. It was noted during the testing of the Talent Search – Upward Bound Math and Science program (UBMS) program eligibility that there is no documentation to indicate that applications were formally reviewed or approved by the program director. Cause: Required internal control review procedures were not documented and hence, no evidence was available to support that such review was performed. Effect: Although the students tested appear to be eligible to receive program services, this lack of program director review could’ve led to students that weren’t eligible receiving program services. Identification of repeat finding: No. Recommendation: The University should increase in efforts through training to ensure that all controls related to eligibility for all TRIO programs are properly followed. Views of Responsible Officials: As noted in the audit finding, auditor sample testing disclosed no instances of noncompliance related to participant eligibility to receive program services. While the University’s internal controls over compliance were not fully documented (lack of support proving eligibility review), at a minimum, University staff were aware of program eligibility requirements and first level internal controls functioned properly (no compliance sample errors). Going forward, the University will more stringently adhere to its procedures that include documentation of program eligibility review. Corrective Action: To strengthen internal controls, the TRIO program has implemented a corrective action plan requiring that all application forms be thoroughly reviewed for completion and proper authorization prior to submission. Each form must now include a verified approval signature from the designated supervisor or administrator. Furthermore, all approved TRIO application forms are securely uploaded and stored in the University's OneDrive system, allowing authorized personnel to view, track and confirm approvals in real time. This corrective action ensures documentation integrity, promotes transparency, and supports continuous program readiness for internal and external review. The following documentation protocols will ensure full compliance and transparency for all application forms. *Be thoroughly completed with no missing fields or attachments. *Include a verified approval signature from the designated supervisor or authorized administrator before acceptance. *Be uploaded immediately to the University's secure OneDrive system for real-time viewing, tracking and audit accesss by authorized personnel by the 15th of every month. This process creates a standardized worflow that ensures every TRIO form is accurately documented, authorized, and available for verification at all stages of the review cycle. Responsible Person(s): Stephanie White, AVP/Comptroller swhite@vuu.edu 804 257-5745 Linda Jackson, VP Sponsored Research and Innovation lrjackson@vuu.edu 804 257-5807 Gloria Foote, Grant Accountant gjfoote@vuu.ed 804 257-5781. Planned date of Completion of Corrective Action: December 31, 2025
The Food Service Director has implemented a corrective plan focused on (1) re-training on production record requirements, (2) real-time verification and monitoring, (3) escalation for noncompliance, and (4) sustained oversight until compliance is consistent. The District will maintain documentation ...
The Food Service Director has implemented a corrective plan focused on (1) re-training on production record requirements, (2) real-time verification and monitoring, (3) escalation for noncompliance, and (4) sustained oversight until compliance is consistent. The District will maintain documentation of monitoring and follow-up to demonstrate that corrective actions are in place and effective. Implementation: December 1, 2025
CORRECTIVE ACTION PLAN FINDING 2025-002 Finding Subject: Special Education Cluster (IDEA) – Suspension and Debarment Contact Person Responsible for Corrective Action: Jeremiah Hruschak, Assistant Director of Financial Services; 260-0100x1006; jhruschak@eacs.k12.in.us Views of Responsible Officials: ...
CORRECTIVE ACTION PLAN FINDING 2025-002 Finding Subject: Special Education Cluster (IDEA) – Suspension and Debarment Contact Person Responsible for Corrective Action: Jeremiah Hruschak, Assistant Director of Financial Services; 260-0100x1006; jhruschak@eacs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: East Allen County Schools will establish and document a formal internal control procedure to ensure compliance with federal suspension and debarment requirements for all covered transactions (contracts, subawards, or purchases ≥ $25,000 using federal funds). The procedure will include the following: • Prior to entering any covered transaction expected to equal or exceed $25,000 with federal funds, the purchasing or accounts payable staff will verify the vendor’s status by checking SAM.gov Exclusions. • Zoom training with Directors and Grant Coordinators to verify SAM.gov for vendor disbarment. A screenshot or PDF export of the SAM.gov search results (showing the vendor is not excluded) will be obtained and attached to the purchase requisition or contract file. If not listed on SAM.gov, coordinators will request signed letters from vendors regarding status. • A standardized suspension and debarment verification checklist will be incorporated into the purchasing process for all federal-fund expenditures meeting the threshold. • Annual training (pending employee turnover) will be provided to staff involved in federal purchasing/procurement on the suspension and debarment requirements and the new verification process. • The Assistant Director of Finance perform periodic reviews of a sample of federal purchases ≥ $25,000 to confirm compliance. These controls will prevent future noncompliance with 2 CFR 180.300 and 2 CFR 200.214. Anticipated Completion Date: March 31, 2026
Segregation of Duties - Auditor’s recommendation: We recognize that the District has attempted to mitigate the lack of segregation of duties by having other individuals perform certain ancillary duties of record-keeping including: opening the mail; signing of checks; distribution of payroll and vend...
Segregation of Duties - Auditor’s recommendation: We recognize that the District has attempted to mitigate the lack of segregation of duties by having other individuals perform certain ancillary duties of record-keeping including: opening the mail; signing of checks; distribution of payroll and vendor checks; and bank reconciliations. The District should continue to obtain involvement from its Board of Education in reviewing monthly financial and expenditure reports. District’s Response: The District understands the importance of having strong segregation of duties and will attempt to separate certain responsibilities as outlined above.
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements - Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting jour...
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements - Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. District’s Response: The District has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the District considers such assistance provided by the auditors to be the most cost effective in preparing such information.
FINDING 2025-003 Contact Person Responsible for Corrective Action: Diana Smith Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Along with continuing current control processes, the Registrar will include the Director...
FINDING 2025-003 Contact Person Responsible for Corrective Action: Diana Smith Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Along with continuing current control processes, the Registrar will include the Director of Grants and Assessments in the email to the Data Specialist regarding the withdrawal. A monthly report will be generated by the Data Specialist and given to the Director of Grants and Assessments to verify the withdrawals have been completed appropriately. Anticipated Completion Date: February 2026
FINDING 2025-002 Contact Person Responsible for Corrective Action: Christine Clarahan Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: A monthly checklist was created that will be used by those in the Food Services a...
FINDING 2025-002 Contact Person Responsible for Corrective Action: Christine Clarahan Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: A monthly checklist was created that will be used by those in the Food Services administration team office. The checklist includes the task, line for initials and date that task was completed. Tasks include Direct Certification download, spot checking after the Direct Certification download, verifying Food Service deposits, and other monthly tasks. Anticipated Completion Date: November 18, 2025
Finding No: 2025-004 Condition: The District receives Title I funding and determines eligibility for schoolwide programs based on attendance numbers derived from free and reduced lunch counts. During the audit, we noted that the district’s process for compiling these attendance numbers involves the ...
Finding No: 2025-004 Condition: The District receives Title I funding and determines eligibility for schoolwide programs based on attendance numbers derived from free and reduced lunch counts. During the audit, we noted that the district’s process for compiling these attendance numbers involves the grant manager obtaining a report from the Business Office, which is generated from the food service platform as of a specific day. However, the district was unable to reproduce the report used to complete the Title I application and supporting documentation for the reported figures was not available for review. Plan: The District will maintain all reports used to compile attendance figures for the Title I grant. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Mark Orszula, CSBO
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. Th...
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. This error appears to be isolated to January; however, it would likely have been prevented if a review process were in place. Plan: The District will implement a system in which meal count claims will have secondary approval by the CSBO. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Mark Orszula, CSBO
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.568 All Awards Federal Financial Assistance Listing # 10.569 All Awards Food Distribution Cluster Finding Summary: ...
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.568 All Awards Federal Financial Assistance Listing # 10.569 All Awards Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations and reviews for The Emergency Food Assistance Programs. Responsible Individuals: Kate Molbert, COO David Stachon, CFO Corrective Action Plan: The GPFB will ensure all documents for TEFAP programs have proper signatures by necessary parties going forward. An electronic signature process has been implemented to make the dissemination, review and storage of this process easier. Also, additional staffing has been hired to manage this process in the form of a Programs and Operations Compliance Manager with substantial compliance experience. Anticipated Completion Date: Immediate
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.565 All Awards Federal Financial Assistance Listing # 10.568 All Awards Food Distribution Cluster Finding Summary: ...
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.565 All Awards Federal Financial Assistance Listing # 10.568 All Awards Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, multiple payroll allocation errors to programs were identified. Responsible Individuals: Kate Molbert, COO David Stachon, CFO Corrective Action Plan: This issue was fixed in FY25. The finding still exists due to July and August payrolls that occurred prior to the fix. After this was brought to our attention in the prior audit, it has been fixed going forward. We discussed this issue with our outsourced payroll provider, PRO Resources. We’ve opted into their upgraded online portal and now have access to better view, change and review allocations ourselves. Anticipated Completion Date: Completed
MANAGEMENT AGREES WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WAS FUNDED ON NOVEMBER 18, 2024 IN THE AMOUNT OF $575. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACCOUNT IS PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WAS FUNDED ON NOVEMBER 18, 2024 IN THE AMOUNT OF $575. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACCOUNT IS PROPERLY FUNDED IN THE FUTURE.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
Condition & Criteria: The College did not consistently report Direct Loan and Pell Grant origination/disbursement records to the COD system within the required 15-day window (or November 30, 2024 deadline), due to EDConnect software and system issues. Auditor's Recommendation: Implement additional p...
Condition & Criteria: The College did not consistently report Direct Loan and Pell Grant origination/disbursement records to the COD system within the required 15-day window (or November 30, 2024 deadline), due to EDConnect software and system issues. Auditor's Recommendation: Implement additional processes to ensure timely reporting and prompt resolution of software issues. Corrective Action: The Financial Aid department is implementing automated alerts and conducting weekly compliance checks to ensure timely and accurate processing. The team is coordinating closely with TVCC IT to prevent future delays, and software or system performance issues affecting financial aid operations will be escalated as a priority. In addition, staff will receive training on federal reporting timelines and established escalation protocols to strengthen long-term compliance. Responsible person: Director of Financial Aid, with oversight from Vice President of Student Services. Anticipated Completion Date: Begin implementation immediately and accomplish full implementation by Spring 2026; ongoing monitoring.
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses ...
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses attended and fees incurred. Corrective Action: The Financial Aid Department now verifies actual course enrollment prior to disbursement for specialized programs, ensuring accuracy and compliance. Beginning Winter term 2026, mid-term audits for the aviation program have been implemented to strengthen oversight. Additionally, policy updates now require real-time cost of attendance adjustments for all individualized programs to maintain consistency and alignment with federal regulations. Responsible Person: Director of Financial Aid, with support from Aviation Program Director. Anticipated Completion Date: Begin implementation immediately and accomplish full implementation by Spring 2026; ongoing monitoring.
The District will review federal procurement requirements to ensure proper documentation of suspension and debarment checks of vendors, prior to contracts and purchases over the covered transaction threshold
The District will review federal procurement requirements to ensure proper documentation of suspension and debarment checks of vendors, prior to contracts and purchases over the covered transaction threshold
The District will review federal procurement requirements to ensure proper documentation and authorization procedures are followed
The District will review federal procurement requirements to ensure proper documentation and authorization procedures are followed
The District will review the work performed by the individual preparing the reports before submission
The District will review the work performed by the individual preparing the reports before submission
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made depos...
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made deposits into the reserve for replacement to make up the shortfall. Management will work with the Bank and HUD to ensure the accuracy of the “true-up” payments made.
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