Corrective Action Plans

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February 25, 2026 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-002 – AL# 14.181 Supportive Housing for Persons with Disabilities (Section 811) Area: Eligibility In accordance with 24 CFR section 891.410, section 5.230, and OMB No. 2502-0204, owner shall re-exami...
February 25, 2026 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-002 – AL# 14.181 Supportive Housing for Persons with Disabilities (Section 811) Area: Eligibility In accordance with 24 CFR section 891.410, section 5.230, and OMB No. 2502-0204, owner shall re-examine tenant eligibility at least every 12 months with respect to family income, composition and is required to obtain signed consent forms from assistance applicants. In accordance with HUD Multifamily Occupancy Handbook, Chapter 7, annual certification should be completed and submitted through TRACS within 15 months from previous year’s anniversary date. Based on testing performed recertifications did not occur within the required time period. It is recommended to add monitoring controls to help ensure recertifications are completed in accordance with 24 CFR section 891-410, section 5.230, and OMB No. 2502-0204. CLIENT PLANNED ACTION: (1) Annual recertification report will be reviewed monthly with ComCap Management to ensure timely completion of all recertifications. Demands will be given to tenants if recertifications are not completed within 60 days of initial notification. (2) Monthly dashboards will continue to be produced and reviewed with ComCap Management. The monthly dashboards include annual recertifications, occupancy/vacancy, and move-in/move-outs. CLIENT RESPONSIBLE PARTY: Darla Goddard, Director of Real Estate COMPLETION DATE: 01/01/2026
February 25, 2026 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-002 – AL# 14.157 Supportive Housing for the Elderly (Section 202) Area: Eligibility In accordance with 24 CFR section 891.410, section 5.230, and OMB No. 2502-0204, owner shall re-examine tenant elig...
February 25, 2026 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2025 AUDITOR FINDING: 2025-002 – AL# 14.157 Supportive Housing for the Elderly (Section 202) Area: Eligibility In accordance with 24 CFR section 891.410, section 5.230, and OMB No. 2502-0204, owner shall re-examine tenant eligibility at least every 12 months with respect to family income, composition and is required to obtain signed consent forms from assistance applicants. In accordance with HUD Multifamily Occupancy Handbook, Chapter 7, annual certification should be completed and submitted through TRACS within 15 months from previous year’s anniversary date. Based on testing performed recertifications did not occur within the required time period. It is recommended to add monitoring controls to help ensure recertifications are completed in accordance with 24 CFR section 891-410, section 5.230, and OMB No. 2502-0204. CLIENT PLANNED ACTION: (1) Annual recertification report will be reviewed monthly with ComCap Management to ensure timely completion of all recertifications. Demands will be given to tenants if recertifications are not completed within 60 days of initial notification. (2) Monthly dashboards will continue to be produced and reviewed with ComCap Management. The monthly dashboards include annual recertifications, occupancy/vacancy, and move-in/move-outs. CLIENT RESPONSIBLE PARTY: Darla Goddard, Director of Real Estate COMPLETION DATE: 01/01/2026
Corrective Action Plan for Greater Eastern Oregon Development Corporation Greater Eastern Oregon Development Corporation respectfully submits the following corrective action plan in response to a finding in our audit for the fiscal year ended June 30, 2025. The audit was completed by the independent...
Corrective Action Plan for Greater Eastern Oregon Development Corporation Greater Eastern Oregon Development Corporation respectfully submits the following corrective action plan in response to a finding in our audit for the fiscal year ended June 30, 2025. The audit was completed by the independent auditing firm Anderson Boylan Ramos, P.C. of Hermiston, Oregon. The finding from the June 30, 2025 audit is discussed below with the corresponding Action Plan listed. The finding from the June 30, 2025 Schedule of Findings and Questioned Costs are discussed below. FINDING – FEDERAL AWARD AUDIT PROGRAM AUDIT 1. Finding 2025-001 a. Reportable Instance of Noncompliance of Financial Reporting: Greater Eastern Oregon Development Corporation is required to annually report to the Economic Development Administration on the EDA Cares RLF. Amounts reported on the June 30, 2024 report did not agree to the underlying financial data and were incorrectly reported by category. b. Recommendation: We recommend that employees involved in the reporting process review from ED-209 reporting rules and regulations. It is also recommended that any incorrect reports filed with the EDA be corrected prior to the submission of the June 30, 2025 report. c. Action Taken: As recommended, employees that are involved in the reporting process will review reporting rules and regulations. GEODC will also correct any incorrect filings with the EDA in regards to its reporting on the EDA Cares RLF. d. Responsible Party: Tory Stinnett, Executive Director e. Anticipated Completion Date: The Corporation anticipates taking corrective action for the June 30, 2024 report prior to filing the most recent June 30, 2025 report.
Criteria: Neither the PHA nor any of its contractors or subcontractors may enter into any contract or arrangement in connection with the HCV program in which any of the following classes of persons has any interest, direct or indirect, during tenure or for one year thereafter (2) Any employee of the...
Criteria: Neither the PHA nor any of its contractors or subcontractors may enter into any contract or arrangement in connection with the HCV program in which any of the following classes of persons has any interest, direct or indirect, during tenure or for one year thereafter (2) Any employee of the PA, or any contractor, subcontractor or agent of the PHA, who formulates policy or who influences decisions with respect to the programs (24 CFR sections 982.161). Condition: During the audit, it was noted that multiple (3) participants of the HCV program were either employees or relatives of employees. Context: According to 24 CFR 982.161, any employee who exercise authority over the PHA cannot receive benefits. However, past OIG action has issued findings to Public Housing Authority entitles when any employee and immediate family member receives benefits as unallowable cost. The OIG's concern seems to be that the tenant may have received special treatment at admission or is currently receiving special treatment related to rent calculation, unit inspections, etc. The OIG regarded the HAP costs as ineligible and recommended that the PHA re-pay the funds. Cause: The non-compliance appears to stem from ambiguity in the Housing Authority's policy relating to Conflict of Interest. Effect: The Conflict of Interest undermines the community's trust with the Housing Choice Vouchers Program. It also represents a risk of improper use of federal funds and can impact the credibility and effectiveness of the program. Recommendations: Update the Authority's Conflict of Interest policy and implement more stringent procedures for monitoring Conflict of Interest. Questioned Costs: The exact monetary impact needs further investigation to determine the amount of HAP that should have been unallowable for the period of non-compliance. Management Views: Management Agrees - see Corrective Action Plan ecommended in the Independent Auditor's Report as it pertains to internal controls over our HCV program. Please note, our agency is in the midst of transitioning between executive directors - therefore, we request additional time so that our personnel policy can be gone through by our new executive director, after which such individual is hired, reviewed by our agency attorney, and then approved by our board of commissioners. This process will take additional time to complete. Our agency will review its internal control over annual policy reviews to ensure that all policies, not just our "Coriflict of Interest Policy", are adhered to. Below is our current HACPFC Coriflict of Interest Policy, followed by our proposed amended Coriflict of Interest Policy. You are to avoid placing yourself in a position that may create or lead to a conflict of interest or the appearance of one. A conflict of interest exists when there is evidence of or the appearance that a commissioner's/employee's personal interests have influenced or may influence HACPFC transactions or operations, or that these interests take precedence over the interests, goals, and/or mission of HACPFC. Or a situation where a benefit or advantage of an economic or tangible nature that might inure to an HACPFC employee, creates a potential bias or loss of independence of judgment in the performance of that employee's or Commissioner's duties. For the purpose of this policy, a relative is defined as a spouse/significant other, parent, sibling, child, grandchild, grandparent, parent-in-law, brother-in-law, sister-in-law, daughter-in-law, son in-law, aunt, uncle, niece, nephew, cousin, stepparent, or stepchild. An actual, potential, or perceived conflict of interest occurs when an employee, contractor, agent, officer, or member of the Board of Commissioners is in a position to influence a decision that may result in a personal gain for that employee or for a relative as a result of the HACPFC's business dealings. Employees need to refrain from conducting business that presents a conflict of interest as described above. No "presumption of guilt" is created by the mere existence of a relationship with outside firms. However, if employees have any influence on transactions involving purchases, contracts, or leases, it is imperative that they disclose to the Executive Director of HACPFC as soon as possible the existence of any actual or potential conflict of interest so that safeguards can be established to protect all parties. Employees should avoid any situations which involves or may involve a conflict between their personal interest and the interest in HACPFC or any other arrangement or circumstances including family or other personal relationships, which might dissuade the employees from acting in the best interest of HACPFC. All employees will be required to sign the Employee Conflict of Interest Disclosure Form as part of employment. You are also prohibited from having any personal interest, directly or indirectly, in any transaction with HACPFC or from otherwise using your position to secure special privileges for yourself or others. You may not directly or indirectly give or receive any compensation, gift, reward or gratuity from any source other than HACPFC for any matter or service which relates directly or indirectly in any way to your work for HACPFC. You also may not accept or engage in any business, personal or professional activity that might be reasonably expected to require or induce you to disclose confidential or proprietary information regarding HACPFC or its applicants, tenants or program participants. If you have any questions regarding whether a conflict may exist, you should ask the Executive Director before engaging in the conduct at issue. Proposed Personnel Policv Change/ added language in red: Gifts: Conflict of Interest: You are to avoid placing yourself in a position that may create or lead to a conflict of interest or the appearance of one. A conflict of interest generally exists when there is evidence of or the appearance that a commissioner's/employee's personal interests have influenced or may influence HACPFC transactions or operations, or that these interests take precedence over the interests, goals, and/or mission of HACPFC.
Criteria: HUD requires that all units under the Housing Choice Vouchers Program meet specific Housing Quality Standards (HQS). In cases of failed inspections, timely re-inspections are mandatory, and if compliance is not achieved, abatement of Housing Assistance Payments (HAP) or voucher cancellatio...
Criteria: HUD requires that all units under the Housing Choice Vouchers Program meet specific Housing Quality Standards (HQS). In cases of failed inspections, timely re-inspections are mandatory, and if compliance is not achieved, abatement of Housing Assistance Payments (HAP) or voucher cancellation is required Condition: During the audit, it was noted that in one (1) instance a unit that failed its HQS inspection (life­threatening failure) did not undergo a subsequent reinspection within the proper 24-hour time period: Consequently, the required abatement of HAP or cancellation of the housing voucher was not executed. Context: This finding represents an issue within the Housing Voucher Cluster program, as it was identified in one (1) files tested out of a sample of two (2) failed inspections. It highlights a need for more rigorous enforcement and monitoring ofHQS compliance Cause: The non-compliance appears to stem from oversight or procedural lapses in the enforcement of HQS within the Housing Voucher Cluster program. This may be due to inadequate training, monitoring, or failure to adhere to established protocols Effect: This non-compliance undermines the integrity of the Housing Choice Vouchers Program and may lead to tenants living in substandard conditions. It also represents a risk of improper use of federal funds and can impact the credibility and effectiveness of the program. Recommendation: Implement more stringent procedures for monitoring HQS compliance, including timely reinspection and enforcement of HAP abatement or voucher cancellation. Enhance training for staff involved in the HQS process to ensure a thorough understanding of compliance requirements. Establish a system of regular audits to identify and rectify lapses in HQS enforcement promptly. Questioned CostsL The exact monetary impact needs further investigation to determine the amount of HAP that should have been abated for the period of non-compliance. A. HACPFC Corrective Actio11 P/all: Our staff who conduct the HCV inspections are certified in both HQS and NSP IRE Standards. This failure to re-inspect this life-threatening finding within 24 hours after the discovery was an obvious oversight by our inspection staff as they are all aware of this requirement. However, the Agency will review internal controls related to training and will ensure that all inspectors are provided with additional training to reinforce compliance with the 24-hour re-inspection requirement and follow up with the landlord to verify compliance and penalty if required. The HA CP FC will also continue to review process over the auditing of tenant files to ensure that there are no lapses in the compliance requirements. B. A1tticipated Completion Date: This is already in progress.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE INSTANCE OF NONCOMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.582 2025-002 Internal Control Over Compliance and Repor...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE INSTANCE OF NONCOMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.582 2025-002 Internal Control Over Compliance and Reportable Noncompliance With Federal Procurement Requirements Finding Summary 2 CFR § 200.320 requires Independent School District No. 280 (the District) to establish and maintain effective internal control over compliance with requirements applicable to its federal program expenditures, including applicable procurement requirements. The District did not have sufficient controls in place within the child nutrition cluster federal programs to ensure compliance with federal procurement requirements related to methods of procurement, which resulted in reportable a instance of noncompliance. Corrective Action Plan Actions Planned – The District will review policies and procedures relating to procurement for its child nutrition cluster federal programs to ensure that multiple quotations are obtained when required and that adequate documentation is retained. The District solicited quotes and retained the necessary documentation for the noncompliant contract in fiscal year 2026. Official Responsible – The District’s Director of Finance, Heidi Savatdy. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Chief Administrative Officer, Craig Holje, will monitor the implementation of these corrective actions as implemented by the Director of Finance to ensure appropriate controls over federal procurement requirements are in place and being consistently applied to ensure multiple quotations are solicited and retained for contracts awarded for goods or services in excess of the District’s micro-purchase threshold, as required by the Uniform Guidance.
McDowell County Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: Finding 2025-004 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Comp...
McDowell County Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: Finding 2025-004 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Corrective Actions for Findings 2025-004 also apply to State requirements and State Awards. Lynn Freeman, Medicaid Program Manager We will provide refresher trainings on household composition, electronic income/resource matches, Request for information requirements, and timely recertifications, with weekly sessions on new policy changes. Medicaid management will collaborate with upper management on solutions to enhance quality control capacity and address staffing constraints. This will include the backlog from the Hurricane Helene-related statewide recertification pause by prioritizing workload distribution. Monthly reviews will continue to be conducted to meet state-mandated requirements, with continued focus on strengthening controls. All required trainings will be completed by November 30, 2025. Section IV - State Award Findings and Question Costs Alison Bell, Finance Officer The 2024 audit report was delayed due to the County's audit firm experiencing a significant cybersecurity incident between October 2024 and February 2025; fieldwork had been completed in October however the financials could not be finished timely and subsequently the data collection was filed late. The audit firm has accepted full responsibility for the delay and informed the County that they would not longer provided audit services to counties. McDowell County issued requests for proposals to all firms qualified to perform county audits for fiscal year 2025 and intends to submit their data collection timely moving forward. June 30, 2026 Section III - Federal Award Findings and Question Costs 161
Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and programregulations. The University continues to enhance its internal controls, policies and procedures toensure the appropriate documentation to support is maintained. Primary Control Enha...
Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and programregulations. The University continues to enhance its internal controls, policies and procedures toensure the appropriate documentation to support is maintained. Primary Control Enhancements. During the next Annual Performance Report (APR) reporting cycle, the AVP for Student Affairs, TRIO and Well-being as well as the respective TRIO program director will correct the inaccurately reported Project Entry Date and First Date of Postsecondary Enrollment for affected participants. These data elements are editable within the APR system and will be updated to align with official institutional and program records. Supporting Controls and Training. To support ongoing compliance, the Federal TRIO Programs have strengthened internal controls and will continue to conduct annual reviews of policies, procedures, and internal controls to ensure alignment with federal regulations and grant administration best practices. To ensure consistent implementation, monthly staff trainings are conducted using the TRIO General Guidelines. In addition, TRIO staff will continue to participate in local and national professional development opportunities to enhance grant management knowledge and standardize practices related to program administration and federal reporting. To ensure all APR reports are accurate moving forward, all APR reports will be completed prior to the deadline and the TRIO staff along with GSPAR will review for accuracy and completeness. Monitoring and Quality Assurance. To further strengthen compliance efforts, the AVP for Student Affairs, TRIO, and Well-being developed a comprehensive TRIO General Guidelines resource for program personnel. The TRIO General Guidelines will be updated to include new JCSU policies that relate to TRIO program management. Informed by Johnson C. Smith University institutional policies, federal TRIO regulations, and best practices from peer institutions, the guide addresses grant administration, record-keeping, participant eligibility, program services, fiscal management, personnel, and travel. TRIO personnel, in collaboration with the Assistant Vice President (AVP) for Student Affairs, TRIO, and Well-being, will continue to conduct regular reviews of participant files and program records to verify data accuracy and regulatory compliance prior to federal reporting. Sustained Oversight. The university will engage in continuous monitoring and evaluation to assess the effectiveness of these corrective actions, identify opportunities for improvement, and maintain full compliance with all applicable regulatory requirements. Anticipated Completion Date: June 2026
Corrective Action Plan: GSPAR will improve its internal controls, policies, and procedures to mandate a physical inventory annually. GSPAR will attest/certify all inventory once every two years, beginning in May 2026 to rectify the remaining audit deficiency. This ensures accurate tracking and accou...
Corrective Action Plan: GSPAR will improve its internal controls, policies, and procedures to mandate a physical inventory annually. GSPAR will attest/certify all inventory once every two years, beginning in May 2026 to rectify the remaining audit deficiency. This ensures accurate tracking and accountability of assets. In partnership with Moore & Van Allen JCSU also updated our equipment management policy, procedures and training modules to address this audit finding (updated January 15, 2026). Anticipated Completion Date: June 2026
Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and program regulations. The University continues to enhance its internal controls, policies, and procedures to ensure the appropriate documentation to support is maintained, and to ensure tha...
Corrective Action Plan: The University is committed to ensuring compliance with all federal, institutional, and program regulations. The University continues to enhance its internal controls, policies, and procedures to ensure the appropriate documentation to support is maintained, and to ensure that level of effort is appropriately documented and reported. To this end the University enlisted the support of Moore & Van Allen and associates law firm to support in developing enhanced policies, procedures, and training modules to support an increased level of compliance support. Moore & Van Allen is a wellrespected international law firm that specializes in reporting compliance and compliance training.To address the specific audit concerns Moore & Van Allen in conjunction with the JCSU executive cabinet, Government Sponsored Programs, the President and Board of Trustees to develop these policies, supporting procedures and training modules. These policies have been approved as of the January 15, 2026 Board of Trustees meeting: Time and Effort Reporting Policy, Government- Sponsored Equipment and Property Management Policy, Post-Award Management Policy, Grant Records Management Policy and Revised Extra Compensation for Faculty and Staff Policy. The level of effort reporting process has been modified to a consistent reporting for all campus awards. Level of effort reports are done by academic term, and the reports are due within 60 days following the end of the term. The Office of Government Sponsored Programs (“GSPAR”) has implemented monitoring and tracking measures to all reports are captured and completed according to federal guidelines. A system of multiple reviews has been implemented to help in reducing errors in reporting and increase efficiency in timeliness of the reports. Additionally, GSPAR intends to work closely with the Human Resources division to ensure accurate and efficient Time and Effort reporting. To address this concern, the Payroll unit has been reorganized into the Business and Finance Office to streamline communication and time and effort report fidelity between Payroll and GSPAR. In addition, the University mandated participation in compliance training for all faculty and staff; participants are required to submit an acknowledgment that they participated in the training and are aware of the compliance requirements. The mandatory training will occur annually for the university and all new grant award recipients will receive this training as part of their grant startup process. All GSPAR employees will also participate in training related to time and effort and allowable costs compliance, annually. Specific to the TRIO programs, as the result of a re-organization in February 2025 the University created a new position: Assistant Vice President (AVP) for Student Affairs, TRIO, and Well-being. This role will oversee Time and Effort Reporting, Annual Performance Report submissions, and financial transactions, ensuring accuracy and adherence to all relevant policies, regulations, and procedures. Additionally, this position will support professional development initiatives to enhance grant management and compliance. The AVP will also support university efforts to conduct regular program reviews to ensure proper documentation supporting TRIO eligibility and adherence to program requirements. To improve program knowledge and standardize practices, TRIO personnel will continue engaging in professional development offered locally and nationally. Internally, the TRIO Leadership Team (TRIO Project Directors and SVP of Student Enrollment & Retention Management) established TRIO Professional Development Day, a two-day training designed specifically for JCSU TRIO staff. These sessions provide guidance on university policies, financial compliance, Time and Effort reporting, effective record-keeping, and data management. The event also includes a roundtable discussion to promote collaboration and shared learning across programs. In addition, the TRIO Leadership Team will continue to explore best practices from high-functioning TRIO programs. To enhance communication and strengthen internal controls, the TRIO Leadership Team implemented monthly TRIO Program meetings. These meetings, involving TRIO Project Directors and the Senior Vice President of Strategic Enrollment and Retention Management, facilitate discussions on compliance, streamline processes, and support policy development. Additionally, the TRIO Leadership Team established monthly interdepartmental meetings among TRIO programs, the Division of Government Sponsored Programs and Research, and the Division of Business and Finance to further ensure alignment with institutional and federal requirements. Human Resources will also participate in future meetings to review Time and Effort Reporting procedures. TRIO Project Directors maintain ongoing communication with the Department of Education Program Officer, seeking written guidance on allowable costs, staffing adjustments, and fund reallocations, when necessary. Continuous monitoring and evaluation will ensure the effectiveness of these corrective actions, allowing the university to identify areas for ongoing improvement and maintain full compliance with all regulatory requirements Anticipated Completion Date: December 2026
Corrective Action Plan: To address the deficiencies identified in Finding 2025-008, the University has implemented and continues to strengthen a Registrar-led corrective action framework focused on improving the accuracy, timeliness, and oversight of Campus-Level and Program-Level enrollment reporti...
Corrective Action Plan: To address the deficiencies identified in Finding 2025-008, the University has implemented and continues to strengthen a Registrar-led corrective action framework focused on improving the accuracy, timeliness, and oversight of Campus-Level and Program-Level enrollment reporting to the National Student Loan Data System (NSLDS). Primary Control Enhancements. The University has engaged Strata Information Group (SIG) to support validation and configuration of enrollment reporting functionality within Ellucian Colleague. This engagement assists the Registrar’s Office in ensuring that enrollment status changes, credential completions, and program-level data are transmitted accurately through established reporting processes. Responsibility for enrollment reporting remains with the Office of the Registrar, with SIG serving in a technical advisory capacity. The Office of the Registrar will establish a structured enrollment reporting cadence, including submission of enrollment files on a bimonthly basis. This reporting schedule will ensure timely identification and reporting of enrollment status changes in compliance with federal requirements and reduce reliance on ad hoc or event-driven reporting. Supporting Controls and Training. To further strengthen upstream data integrity, the Registrar’s Office will implement enrollment governance controls, including restricting late graduation applications and limiting major declarations to designated academic periods. These controls reduce late-cycle data changes that previously contributed to reporting inconsistencies. Monitoring and Quality Assurance. The Office of the Registrar has institutionalized a formal quality assurance calendar requiring enrollment reporting reviews at least twice per semester. These reviews validate the accuracy and timeliness of Campus-Level and Program-Level enrollment data reported to the National Student Clearinghouse (NSC) and, by extension, NSLDS. As part of this monitoring framework, the Registrar’s Office will conduct periodic sampling of reported enrollment records to confirm compliance with reporting timelines and verify the effectiveness of enrollment reporting controls. Sustained Oversight. Any discrepancies identified through quality assurance reviews will be documented, corrected, and evaluated to inform process refinement and prevent recurrence. To support reconciliation and data validation, the Registrar’s Office will meet monthly with the Office of Data Analytics to compare enrollment data within Ellucian Colleague to downstream reporting outputs. Anticipated Completion Date: June 2026
Corrective Action Plan: To address the deficiencies identified in Finding 2025-006, The Offices of Student Accounts and Financial Aid offices (“the Offices”) will improve coordination and communication regarding the timing of fund transfers and refund disbursements. The Offices have established a sc...
Corrective Action Plan: To address the deficiencies identified in Finding 2025-006, The Offices of Student Accounts and Financial Aid offices (“the Offices”) will improve coordination and communication regarding the timing of fund transfers and refund disbursements. The Offices have established a schedule to begin the refund process 10 calendar days of the credit balance creation date to ensure compliance with the 14-day federal requirement. A written processing calendar has been established to track key deadlines and responsibilities. These actions establish preventive controls to ensure all Title IV credit balances are refunded within the federally required timeframe and to prevent recurrence. Ongoing monitoring of this process will ensure the University issues Title IV refunds within 14 days of the credit balance being applied to the student’s account. Anticipated Completion Date: December 2026
Corrective Action Plan: To address the deficiencies identified in Finding 2025-005, the University has implemented and continues to strengthen a comprehensive corrective action framework focused on automating Return of Title IV (R2T4) processing, clarifying cross-functional responsibilities, enforci...
Corrective Action Plan: To address the deficiencies identified in Finding 2025-005, the University has implemented and continues to strengthen a comprehensive corrective action framework focused on automating Return of Title IV (R2T4) processing, clarifying cross-functional responsibilities, enforcing withdrawal data integrity, and institutionalizing quality assurance and supervisory oversight. Primary Control Enhancements. Ellucian Colleague has been configured to automate R2T4 calculations and prevent post-withdrawal disbursements without documented authorization, supported by system-generated audit trails. Supporting Controls and Training. Controls governing withdrawal determination have been strengthened, including required reporting of last date of attendance as a part of grade submission and faculty training to support accurate withdrawal data. This requirement strengthens the integrity of withdrawal data, supports accurate determination of official and unofficial withdrawal dates, and ensures that R2T4 calculations are based on verified enrollment activity. The University has clarified and formalized cross-functional responsibilities related to withdrawal determination and R2T4 processing. Controls now ensure structured communication between academic units, the Office of the Registrar, and the Office of Financial Aid, with defined ownership for initiating, calculating, reviewing, and completing R2T4 determinations. Monitoring and Quality Assurance. To ensure accuracy and timeliness, the University has implemented a secondary review process for all R2T4 calculations. Initial calculations completed in Ellucian Colleague are independently validated using the Return of Title IV calculation tools within the Common Origination and Disbursement (COD) system. This secondary calculation serves as a quality control measure prior to final processing and fund return. In addition, R2T4 activity is subject to periodic quality assurance reviews, including monitoring of calculation timeliness, authorization documentation, and fund return deadlines. Sustained Oversight. Any discrepancies identified by QA reviews are documented, corrected, and reviewed to inform process improvements and staff training. Supervisory oversight is in place to ensure compliance with federal timelines and calculation requirements. Anticipated Completion Date: August 2026
Corrective Action Plan: To address the deficiencies identified in Finding 2025-004, the University has implemented and continues to enhance corrective actions focused on automating loan disbursement notifications, standardizing notification content and timing, strengthening documentation and audit t...
Corrective Action Plan: To address the deficiencies identified in Finding 2025-004, the University has implemented and continues to enhance corrective actions focused on automating loan disbursement notifications, standardizing notification content and timing, strengthening documentation and audit trails, and institutionalizing quality assurance oversight to ensure sustained compliance with federal notification requirements. Primary Control Enhancements. Loan disbursement notifications to the student for Subsidized, Unsubsidized, and Graduate PLUS Loans are now system-generated through Ellucian Colleague, providing automated delivery and a documented audit trail. Notifications are issued upon disbursement processing and delivered through system-supported modalities, including electronic communication and student portal updates. Ellucian Colleague retains a system-generated audit trail documenting the timing and content of each notification, strengthening the University’s ability to demonstrate compliance with federal requirements. This system-based approach eliminates reliance on third-party notification tools previously used and brings direct control of notification sequencing, content, and documentation within the University’s financial aid infrastructure. Supporting Controls and Training. The University has revised the Parent PLUS Loan notification process to ensure that required disbursement information—including the date, amount, and type of loan—is provided directly within the notification communication. While Parent PLUS notifications currently require initiation through a controlled manual process, procedures have been amended to ensure timely issuance, content accuracy, and supervisory oversight during this interim period. The University is actively working with the Ellucian Colleague implementation team to further automate Parent PLUS Loan disbursement notifications and eliminate manual triggering. Until full automation is achieved, documented procedures and quality assurance reviews will serve as compensating controls to ensure compliance with notification timing and content requirements. Monitoring and Quality Assurance. The University established and maintains a formal quality assurance framework to monitor loan disbursement notifications. A quality assurance calendar requires reviews at least twice per semester to confirm that notifications are issued within required regulatory timeframes, include all required elements, and are sent to the appropriate recipient (student or parent). As part of ongoing monitoring, the University has conducted multiple quality assurance reviews of loan disbursement notifications. These reviews have demonstrated improved compliance with notification timing and content requirements while also identifying isolated system sequencing issues that were promptly addressed through configuration updates and enhanced scheduling controls within Ellucian Colleague. Sustained Oversight. Any discrepancies identified through quality assurance reviews are documented, corrected, and evaluated to inform process refinement, system configuration, and staff training. Anticipated Completion Date: September 2026
Corrective Action Plan: To address the deficiency identified in Finding 2025-003, the University has implemented and is continuing to formalize corrective actions focused on strengthening award notification sequencing, automating required communications, and ensuring a verifiable audit trail prior t...
Corrective Action Plan: To address the deficiency identified in Finding 2025-003, the University has implemented and is continuing to formalize corrective actions focused on strengthening award notification sequencing, automating required communications, and ensuring a verifiable audit trail prior to the disbursement of Title IV funds. Primary Control Enhancements. With the assistance of Financial Aid Services (FAS), Ellucian Colleague has been configured to automate award notification generation upon completion of student packaging, creating a system-generated audit trail that documents notification timing relative to disbursement. This automation ensures that award notifications are issued prior to disbursement activity and creates a system-generated audit trail documenting the timing and issuance of the notification. Supporting Controls and Training. Financial Aid staff receive ongoing system and compliance training to reinforce proper sequencing of notifications and disbursements. Monitoring and Quality Assurance. Routine quality assurance reviews confirm that award notifications are issued and documented prior to disbursement, with exceptions documented and corrected. Sustained Oversight. Any exceptions identified will be reviewed, documented, and corrected to ensure sustained compliance. Anticipated Completion Date: June 2026
Corrective Action Plan: To address the deficiencies identified in Finding 2025-002, the University has implemented and is continuing to formalize a comprehensive corrective action strategy focused on strengthening disbursement scheduling, improving system integration, institutionalizing reconciliati...
Corrective Action Plan: To address the deficiencies identified in Finding 2025-002, the University has implemented and is continuing to formalize a comprehensive corrective action strategy focused on strengthening disbursement scheduling, improving system integration, institutionalizing reconciliation and quality assurance processes, and enhancing cross-functional oversight of COD reporting. Primary Control Enhancements. A standardized disbursement and reporting calendar has been established, and system integration between Ellucian Colleague and Jenzabar has been strengthened to improve consistency of cost-of-attendance and disbursement data transmitted to COD. For the 2025–2026 academic year, the Office of Financial Aid and the Office of Student Accounts are disbursing Title IV aid on the second and fourth Tuesday of each month. This schedule has been jointly approved and will continue to be followed by both departments to ensure consistency between disbursement activity and COD reporting. Supporting Controls and Training. Staff participate in targeted training related to COD reporting and cash management through NASFAA and FSA to reinforce knowledge of reporting timelines and requirements. Monitoring and Quality Assurance. A formal financial aid compliance calendar has been developed and institutionalized, outlining required quality assurance (QA) reviews by month, identifying responsible departments, and requiring documented supervisory sign-off. Reviews of COD reporting timelines are conducted twice per semester, and any discrepancies identified are documented, reviewed, and resolved in a timely manner. A systematic monthly reconciliation process has been instituted and is maintained involving the Office of Financial Aid, the Office of Student Accounts, and Budgets & Grants Accounting to ensure consistency across internal systems and COD reporting. Sustained Oversight. Any discrepancies identified through reconciliation are documented, communicated to relevant departments, and resolved, with formal supervisory sign-off required from the Assistant Director of Financial Aid and the Director of Budgets & Grants Accounting. In addition, Financial Aid maintains standing bi-weekly coordination meetings with Student Accounts and Business Office staff to support ongoing alignment related to Title IV disbursement activity and COD reporting timelines. Anticipated Completion Date: June 2026
Corrective Action Plan: To address the deficiencies identified in Finding 2025-001, the University has undertaken and continues to implement a comprehensive corrective action strategy focused on strengthening financial aid systems, standardizing processes, enhancing staff capacity, and institutional...
Corrective Action Plan: To address the deficiencies identified in Finding 2025-001, the University has undertaken and continues to implement a comprehensive corrective action strategy focused on strengthening financial aid systems, standardizing processes, enhancing staff capacity, and institutionalizing quality assurance and oversight mechanisms. Primary Control Enhancements. The University transitioned from PowerFAIDS to Ellucian Colleague as the system of record for financial aid awarding, enabling automated enforcement of packaging, eligibility, and fund-specific awarding rules. System configuration enhancements now support accurate cost of attendance calculations, enforcement of loan limits, and eligibility sequencing based on updated ISIR data, reducing reliance on manual intervention. Supporting Controls and Training. To support the implementation and stabilization of these controls, the University partnered with Financial Aid Services (FAS) in February 2025 to conduct a comprehensive review of financial aid systems, processes, and internal controls. Through this partnership, FAS has provided experienced Colleague specialists to support annual system setup, troubleshooting, validation of awarding rules, and targeted staff training. In addition, Financial Aid staff participate in ongoing professional development through the National Association of Student Financial Aid Administrators (NASFAA) and Federal Student Aid (FSA) to ensure continued proficiency and regulatory awareness. Monitoring and Quality Assurance. A formal quality assurance framework has been institutionalized, requiring eligibility and award accuracy reviews at least twice per semester. Reviews validate FSEOG prioritization by Student Aid Index (SAI), resolution of ISIR comment codes prior to disbursement, compliance with annual and lifetime loan limits, and alignment between cost-of-attendance values maintained in Ellucian Colleague and those reported to COD. Since the implementation of enhanced system controls and QA procedures, the University has conducted multiple eligibility and award accuracy reviews across Title IV programs, including Direct Loans, Pell Grants, and cost-ofattendance reconciliation. These reviews have demonstrated improved accuracy and control effectiveness, while also identifying isolated issues that were addressed through system updates or corrective adjustments. Sustained Oversight. Results of quality assurance reviews are documented, corrected, and analyzed to inform system configuration, staff training, and supervisory oversight. These controls ensure that improvements supported through the FAS partnership are institutionalized within university operations and sustained beyond the initial remediation period. Anticipated Completion Date: June 2026
Response and Corrective Action Plan: The District will implement a process to review and retain records used in determining eligibility as outlined by the Iowa Department of Education and Office of Management and Budget.
Response and Corrective Action Plan: The District will implement a process to review and retain records used in determining eligibility as outlined by the Iowa Department of Education and Office of Management and Budget.
2025-004 REPORTING – CASH MANAGEMENT IMPROVEMENT ACT WEST VIRGINIA STATE TREASURER’S OFFICE (WVSTO) Assistance Listing Numbers: 10.551/10.561/10.555/17.225/20.205/84.010/84.027/84.425/93.558/93.568/ 93.575/93.658/93.659/93.767/93.778/97.036 For the Annual Report filing deadline, December 31, 2025, W...
2025-004 REPORTING – CASH MANAGEMENT IMPROVEMENT ACT WEST VIRGINIA STATE TREASURER’S OFFICE (WVSTO) Assistance Listing Numbers: 10.551/10.561/10.555/17.225/20.205/84.010/84.027/84.425/93.558/93.568/ 93.575/93.658/93.659/93.767/93.778/97.036 For the Annual Report filing deadline, December 31, 2025, WVSTO staff experienced multiple extenuating circumstances including training of newer staff members, medical treatments, illness, and the sudden unexpected passing of a close family member. Realizing that these circumstances would interfere with the timely submission of the Annual Report, an extension was requested on December 30, 2025, with the Bureau of the Fiscal Service and was granted through Friday, January 9, 2026. Regrettably, the extenuating circumstances were not fully resolved by that date, and the report was ultimately submitted on January 14, 2026. The WVSTO remained focused on completing the Report but overlooked the need to request an additional extension. WVSTO staff subsequently met with Angela Smith, Director of the Bureau of the Fiscal Service and staff members Mary Bailey and Christopher Bush from the Revenue Collections Management Team. Director Smith confirmed there will be no penalties assessed due to the late filing. Additionally, WVSTO Banking Services staff will review the internal timeline of CMIA activities and procedures to ensure that future reporting is complete and submitted in a timely manner.
2025-018 PROCUREMENT HIGHER EDUCATION POLICY COMMISSION (HEPC), BLUEFIELD STATE UNIVERSITY (BSU) Assistance Listing Number: Various – Research & Development Cluster Higher Education Policy Commission (HEPC) response: HEPC maintains procurement policies consistent with state law, which is one of the ...
2025-018 PROCUREMENT HIGHER EDUCATION POLICY COMMISSION (HEPC), BLUEFIELD STATE UNIVERSITY (BSU) Assistance Listing Number: Various – Research & Development Cluster Higher Education Policy Commission (HEPC) response: HEPC maintains procurement policies consistent with state law, which is one of the three allowable criteria recognized in 2 CFR §200.320(a)(1)(iv) for establishing a micro purchase threshold of up to $50,000. A Self-Certification letter will be developed and maintained by April 30, 2026, while formally defining micro-purchase thresholds applied to federal awards. This selfcertification letter will be retained as part of our procurement documentation and will provide how the micro-purchase threshold was determined and applied in accordance with 2 CFR §200.320(a)(1)(iv). Bluefield State University (BSU) response: Beginning in FY 2026, the BSU Controller and Director of Purchasing will review the criteria recognized in 2 CFR §200.320(a)(1)(iv) for establishing a micro purchase threshold of up to $50,000. These requirements will be presented to the Board of Governors before June 30, 2026.
2025-017 ALLOWABLE COSTS/COST PRINCIPLES DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.659 DOHS maintains a multi-layered review process for P-card payments. While documentation for the two specific transactions totaling $26 was unavailable at the time of the audit, these transac...
2025-017 ALLOWABLE COSTS/COST PRINCIPLES DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.659 DOHS maintains a multi-layered review process for P-card payments. While documentation for the two specific transactions totaling $26 was unavailable at the time of the audit, these transactions were processed through the same automated financial system that enforces budgetary limits and eligibility checks for all validated cases. Due to current system configurations, P-card transactions must be processed even when documentation is missing. According to the internal controls, any transaction not properly reconciled is marked “Admin Not Reconciled”. This designation indicates the DOHS is aware of the missing documentation, which, according to policy, becomes the cardholder’s responsibility. The Office of Shared Administration (OSA) P-card Division provides reconciliation dates and notifies coordinators of any unreconciled transactions. If a cardholder loses a receipt, they are permitted to submit a lost receipt memo detailing the purchase, accompanied by a supervisor’s signature. The P-card Division has recently begun working closely with the DOHS’s internal purchasing card audit section within the OSA Office of Accountability and Management Reporting (OAMR) to mitigate reconciliation errors. OAMR reviews transactions for accuracy and completeness. Through this coordinated effort, missing documentation or errors are investigated and brought to management’s attention. DOHS will continue to issue monthly notifications to staff emphasizing that all P-card expenditures must be reconciled with proper documentation within one week of the cycle end date. Reconciliations must be electronically reviewed and approved by a supervisor to verify the allowability of costs. To mitigate noncompliance, the P-card Division will work with OAMR to monitor repeated occurrences. Persistent failure to provide documentation or obtain approval may result in the temporary suspension of purchasing privileges. These measures ensure that documentation is maintained, reviewed, and readily available for future audits.
2025-016 ALLOWABLE COSTS/COST PRINCIPLES DEPARTMENT OF HEALTH & HUMAN SERVICES (DOHHS) Assistance Listing Number: 93.658 DOHHS maintains a multi-layered review process for P-card payments. While documentation for the two specific transactions totaling $50 was unavailable at the time of the audit, th...
2025-016 ALLOWABLE COSTS/COST PRINCIPLES DEPARTMENT OF HEALTH & HUMAN SERVICES (DOHHS) Assistance Listing Number: 93.658 DOHHS maintains a multi-layered review process for P-card payments. While documentation for the two specific transactions totaling $50 was unavailable at the time of the audit, these transactions were processed through the same automated financial system that enforces budgetary limits and eligibility checks for all validated cases. Due to current system configurations, P-card transactions must be processed even when documentation is missing. According to the internal controls, any transaction not properly reconciled is marked “Admin Not Reconciled”. This designation indicates the DOHHS is aware of the missing documentation, which, according to policy, becomes the cardholder’s responsibility. The Office of Shared Administration (OSA) P-card Division provides reconciliation dates and notifies coordinators of any unreconciled transactions. If a cardholder loses a receipt, they are permitted to submit a lost receipt memo detailing the purchase, accompanied by a supervisor’s signature. The P-card Division has recently begun working closely with the DOHHS’s internal purchasing card audit section within the OSA Office of Accountability and Management Reporting (OAMR) to mitigate reconciliation errors. OAMR reviews transactions for accuracy and completeness. Through this coordinated effort, missing documentation or errors are investigated and brought to management’s attention. DOHHS will continue to issue monthly notifications to staff emphasizing that all P-card expenditures must be reconciled with proper documentation within one week of the cycle end date. Reconciliations must be electronically reviewed and approved by a supervisor to verify the allowability of costs. To mitigate noncompliance, the P-card Division will work with OAMR to monitor repeated occurrences. Persistent failure to provide documentation or obtain approval may result in the temporary suspension of purchasing privileges. These measures ensure that documentation is maintained, reviewed, and readily available for future audits.
2025-015 ALLOWABLE COSTS/COST PRINCIPLES, ELIGIBILITY DEPARTMENT OF HEALTH & HUMAN SERVICES (DOHHS) Assistance Listing Number: 93.658 DOHHS’s corrective action plan from the prior audit indicated that a system change was made during FY 2025 to prevent future payments to psychiatric facilities from b...
2025-015 ALLOWABLE COSTS/COST PRINCIPLES, ELIGIBILITY DEPARTMENT OF HEALTH & HUMAN SERVICES (DOHHS) Assistance Listing Number: 93.658 DOHHS’s corrective action plan from the prior audit indicated that a system change was made during FY 2025 to prevent future payments to psychiatric facilities from being charged to the Foster Care program. This change did go into effect on September 19, 2024. However, this provider was an anomaly. The facility was a Residential Treatment Facility which was Title IV-E eligible until they received Psychiatric Residential Treatment Facility (PRTF) status in August of 2024, however, they did not provide DOHHS documentation until February 2025. Immediate action was taken by a call ticket to the Technical Call Center to ensure that the PRTF was not continuing to show as IV-E eligible. The staff from the Division of Regulatory Management will continue, as part of their annual licensing review will ensure wvPATH provider records are updated to reflect timely licensing status as well as ensuring that child specific agreements do not lapse. The previously stated Corrective Action Plan remains in place and will continue.
2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to m...
2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to maintain continual monitoring of conducted Annual Unannounced Monitoring Visits required under 45 CFR §98.42(b)(2)(i)(B). Within the tracking spreadsheet, detailed information is input from our documentation system PATH COGNOS Report PCC-PLI 1080. Information includes Provider Name, Provider Number, Provider Type, Specialist Name, and columns for visits conducted and visits not yet conducted. To provide an overall year-to-date calculation of monthly totals/percentages, a Yearly Summary tab is included in the spreadsheet for a quick reference analysis to provide an additional method of tracking visits. As the monthly totals and percentages change, the data updates on the monthly tabs and the Yearly Summary tab. Program Managers have implemented individual efforts to track visits conducted by specialists. The PCC-PLI 1080 report is distributed twice per month by PM II to each Program Manager for review. Specialists have been instructed to include completed annual unannounced monitoring visits on monthly report data, which can then be compared with the PCC-PLI-1080 reports. Additionally, a tracking system has been implemented that requires specialists to pre-plan annual unannounced visits for the 2026 calendar year to ensure visits are completed.
2025-013 West Virginia School of Osteopathic Medicine (WVSOM) response: As of December 2025, WVSOM updated the program enrollment date within the graduation spreadsheet processed out of the Banner system. Going forward, WVSOM registrar will create a calendar reminder to confirm program enrollment on...
2025-013 West Virginia School of Osteopathic Medicine (WVSOM) response: As of December 2025, WVSOM updated the program enrollment date within the graduation spreadsheet processed out of the Banner system. Going forward, WVSOM registrar will create a calendar reminder to confirm program enrollment on the spreadsheet. The reminder function will be used to ensure this step is not missed in the future. WVSOM registrar will check the report diligently for accuracy. Southern West Virginia Community and Technical College (SWVCTC) response: SWVCTC is consulting with the Clearinghouse to better understand and identify any data elements of concern. SWVCTC is working to resubmit enrollment files and will review each file to ensure the data and processes are correct. An internal review by the CIO and Registrar will be done on each submission for a period of at least six months or until all parties are satisfied with the submissions. REPORTING – SPECIAL REPORTING – LIHEAP CARRYOVER AND REALLOTMENT REPORT DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.568 To strengthen internal controls, the Office of Grants Management will reevaluate its current process for tracking LIHEAP program reporting requirements and meeting deadlines. This evaluation, which will be completed by July 1, 2026, will aim to identify specific staff training needs.
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