Corrective Action Plans

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Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that Key Line Items are reviewed and accurately reported to Department of Education as required by regulations. ...
Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that Key Line Items are reviewed and accurately reported to Department of Education as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding resulted from inaccuracies introduced through enhancements made to a Workday-delivered report, which ultimately did not produce correct information. Going forward, we will review and validate the Workday report to ensure it aligns with Student Accounts’ reports and accurately reflects tuition and fees for the academic year. Name(s) of the contact person(s) responsible for corrective action: Jacob Witt, AVP of Financial Aid, 703-284-1532 Planned completion date for corrective action plan: June 2026 If the U.S. Department of Education have questions regarding this plan, please contact the individual(s) noted above.
Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its return of Title IV fund procedures to ensure that calculations are performed with correct inputs as required by regulations. Explanation of dis...
Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its return of Title IV fund procedures to ensure that calculations are performed with correct inputs as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding was driven by incorrect MSMS program start and end dates configured in the University’s new Student Information System (Workday). When processing Return of Title IV (R2T4) calculations, Workday relies on the program start and end dates stored in the system. Due to these dates being incorrect, the R2T4 process calculated an inaccurate number of days enrolled, which resulted in an incorrect earned percentage of Title IV aid and, consequently, an incorrect amount of aid the student was eligible to retain. To address this issue, the University has implemented internal controls to review and verify the start and end dates of each academic year in Workday prior to the start of each semester. In addition, an internal control has been added to ensure the start and end dates of each academic year are reviewed and validated as part of the Return of Title IV processing. Name(s) of the contact person(s) responsible for corrective action: Jacob Witt, AVP of Financial Aid, 703-284-1532 Courtney Carey, University Registrar, 703-284-1523 Planned completion date for corrective action plan: Completed December 2025.
Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Explanation ...
Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The findings were primarily driven by the University’s transition to a new Student Information System (Workday), including the Workday-delivered National Student Clearinghouse (NSC) integrations. These constraints resulted in delays and gaps in enrollment reporting processes, increased processing timelines with the National Student Clearinghouse (NSC), and impacted the timely and accurate transmission of enrollment data to the National Student Loan Data System (NSLDS). In response, Marymount University has developed a formal Standard Operating Procedure (SOP) for National Student Clearinghouse reporting and has begun implementing these procedures during the 2025–2026 academic year. Name(s) of the contact person(s) responsible for corrective action: Courtney Carey, University Registrar, 703-284-1523 Jacob Witt, AVP of Financial Aid, 703-284-1532 Planned completion date for corrective action plan: Completed December 2025.
The Institution implements a formal validation and review process for all Quarterly Progress Reports. As part of this corrective action: • Copies of all checks and/or disbursements included in the report will be attached to each Quarterly Progress Report. • All reported expenditures will be verified...
The Institution implements a formal validation and review process for all Quarterly Progress Reports. As part of this corrective action: • Copies of all checks and/or disbursements included in the report will be attached to each Quarterly Progress Report. • All reported expenditures will be verified against the Institution’s accounting system. • Each Quarterly Progress Report will be reviewed, verified, and certified by the President of the Institution or the Compliance Officer prior to submission to COR3/FEMA. Implementation Plan: • Develop and formalize a written procedure for the preparation, validation, and review of Quarterly Progress Reports. • Designate a responsible official to perform an independent review of the report. • Require supporting documentation, including copies of checks and accounting system reports, as mandatory attachments. • Obtain written certification and signature from the President or Compliance Officer prior to submission. IMPLEMENTATION DATE Immediately RESPONSIBLE PERSON Compliance Officer President of the Institution
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implementation of a formal procurement and suspension and debarment policy that includes procedures over review of the federal suspension and debarred listing, that is in compliance with the Uniform Gui...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implementation of a formal procurement and suspension and debarment policy that includes procedures over review of the federal suspension and debarred listing, that is in compliance with the Uniform Guidance. Procurement policy should include general procurement standards as described by the Uniform Guidance, that include standards on conduct covering conflicts of interest; method of procurement for micro-purchases, small purchases, sealed bids, and proposals; and all other criteria as outlined in 2CFR 200.318 through 200.327. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will develop and implement a procurement policy that is in compliance with the Uniform Guidance. Name(s) of the contact person(s) responsible for corrective action: Sydney Falk, CFO Planned completion date for corrective action plan: February 28, 2026
NSLDS Reporting Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in ...
NSLDS Reporting Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During a typical reporting cycle, all students’ degree information is transmitted to the National Student Clearinghouse (NSC) through a standardized report generated by our Student Information System (Workday). In the instance identified, one student’s graduation status was still pending at the time we submitted degree records for all May 2025 graduates. Once the student’s status was finalized and the degree was officially conferred, we submitted the student’s information manually to the NSC. However, the degree conferral date was reported incorrectly; the actual conferral date was submitted instead of the last day of the student’s final term, which is the required standard. To prevent this issue from recurring, we will discontinue all manual degree submissions to the NSC. Going forward, we will rely exclusively on Workday-generated reports to ensure that all graduation dates are accurate, consistent, and aligned with institutional reporting standards. Name(s) of the contact person(s) responsible for corrective action: James Patton, Assistant Vice President for Academic Affairs and University Registrar Planned completion date for corrective action plan: This change in our data-reporting procedure has already been implemented. The updated process was in place for the most recent degree verification cycle, which was reported to the National Student Clearinghouse on 01-02-2026. If the U.S. Department of Education has questions regarding these plans, please call Dawn Durham at 864-294-2429.
The Village Mayor will provide an updated policy to be approved by the Village Board in 2026.
The Village Mayor will provide an updated policy to be approved by the Village Board in 2026.
Management has currently implemented procedures to have sliding fee application information reconciled to the applicable information in the billing system.
Management has currently implemented procedures to have sliding fee application information reconciled to the applicable information in the billing system.
Management has is currently implementing procedures to have all staff responsible for sliding fee eligibility trained in areas of converting pay information to monthly or annual income for sliding fee determinations. Management will also implement quality review processes to ensure that correct pay ...
Management has is currently implementing procedures to have all staff responsible for sliding fee eligibility trained in areas of converting pay information to monthly or annual income for sliding fee determinations. Management will also implement quality review processes to ensure that correct pay frequency and conversion factors are used.
Management has currently implemented procedures to communicate the approved current sliding fee schedule to the appropriate personnel.
Management has currently implemented procedures to communicate the approved current sliding fee schedule to the appropriate personnel.
Management has currently implemented procedures for grant funded expenditures to ensure that complete documentation supporting the funds requests are available and at the time of the drawdown of the grant funds.
Management has currently implemented procedures for grant funded expenditures to ensure that complete documentation supporting the funds requests are available and at the time of the drawdown of the grant funds.
Reviewing the fund balance monthly and purchasing necessary supplies and staff to keep the balance down.
Reviewing the fund balance monthly and purchasing necessary supplies and staff to keep the balance down.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management review the rates used to calculate management fees to ensure that they agree to the agreed upon percentages outlined in the agreem...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management review the rates used to calculate management fees to ensure that they agree to the agreed upon percentages outlined in the agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that calculated management fees match the agreed upon rates. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Completed on January 31, 2026.
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: Department of Housing and Urban Development requires any surplus funds in the project funds account at the end of the fiscal year to be deposited in a federally insured account within 6...
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: Department of Housing and Urban Development requires any surplus funds in the project funds account at the end of the fiscal year to be deposited in a federally insured account within 60 days following the end of the fiscal year. Condition: As of June 30, 2024, Continuum Supportive Housing of West Hartford, Inc. has a surplus cash of $50,759. The required deposit into a residual receipt account was not made within 60 days following the end of the fiscal year. Questioned costs: None Context: We reviewed the surplus cash calculation noting that the Project has a surplus cash of $50,759 at the end of the fiscal year 24. Surplus cash should have been deposited within 60 days following the end of the fiscal year. Cause: This was an oversight by management. Effect: The required deposit was not made as required by the Department of Housing and Urban Development. Repeat Finding: Yes Recommendation: We recommend management to ensure that required deposits are made 60 days following the fiscal year-end. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Required deposit made by March 31, 2025. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: January 31, 2026.
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon p...
Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon performing testing over payroll disbursements, we noted that there was no approval of the timesheets for the payroll disbursements tested. Questioned costs: None Context: The timesheet for 1 out of 5 payroll disbursements tested was not properly approved by the property manager. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over payroll disbursements. Effect: There is no evidence of proper approval of payroll disbursement. Repeat Finding: Yes Recommendation: We recommend that management strengthen controls over review of payroll. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Although other controls assist to safeguard and mitigate compensation errors, the property manager will ensure that all time sheets are properly approved prior to payment, and if necessary the VP of Operations or the President of the managing agent will provide further assurance of internal controls through reviews. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: January 31, 2026.
Child Nutrition Cluster, National School Lunch Program – Assistance Listing 10.555; passed through the Pennsylvania Department of Education; Grant Period – Year Ended June 30, 2025 Significant deficiency: See deficiency 2025-002 listed below. 2025-002. FOOD SERVICE RECEIVABLES Planned Corrective Act...
Child Nutrition Cluster, National School Lunch Program – Assistance Listing 10.555; passed through the Pennsylvania Department of Education; Grant Period – Year Ended June 30, 2025 Significant deficiency: See deficiency 2025-002 listed below. 2025-002. FOOD SERVICE RECEIVABLES Planned Corrective Action: The Staff Accountant Amber Whited will review receipts after year end to ensure receivables are accurately identified and recorded as receivables. Person Responsible: Staff Accountant (Amber Whited) Anticipated Completion date: Immediately
Finding #2025-001: Type of Finding: Other Finding Responsible Person Abigail Ramos – Program Director Implementation Date January 12, 2026 Views of responsible officials and planned corrective actions Management disagrees with the finding as the assigned Grant Program Official (GPO) with SAMHSA acce...
Finding #2025-001: Type of Finding: Other Finding Responsible Person Abigail Ramos – Program Director Implementation Date January 12, 2026 Views of responsible officials and planned corrective actions Management disagrees with the finding as the assigned Grant Program Official (GPO) with SAMHSA accepted and approved the report and did not note this singular incident as a finding nor did the GPO find BHSST as being non-compliant. Consideration was extended due to the change in Program Director and the impact of the government shutdown affecting access to the assigned GPO. Change in key personnel required prior approval by SAMHSA before the new Program Director could begin working on the project. The new Program Director did have limited access to the assigned GPO due to the impact of the government shutdown and misunderstood that an extension filed was extended to the eRA Commons report versus this report. Reporting deadlines are met by submitting reports prior to the deadline. Challenges that led to the delayed submission have been remedied as clarification was obtained regarding the submission deadlines and process for requesting an extension for both the annual performance and eRA Commons reports. Further management notes this report did not impact the program's ability to continue nor delay any fiscal processes and is not considered a finding by the funder. Auditor Response Based on review and consideration of documentation and responses provided by Management, no documented evidence was available to address the finding of noncompliance.
The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. o Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self...
The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. o Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self-declaration of income and family size. The front office will verify the application, determine the scale for which the patient qualifies, and verify with the Center’s practice management system. The lead biller will review all uploaded documents and approve the sliding fee in real time. o Additional training will take place with front desk personnel. The corrective action outlined above will be monitored on an ongoing basis. The CFO and the Controller will oversee the implementation and report progress to the CEO and Board . Regular internal reviews and reconciliations will be conducted to ensure continued compliance with internal controls and federal requirements.
Incorrect Pell Calculations Planned Corrective Action: Management acknowledges the error in calculation. As a result of change in student information software and financial aid software in conjunction with manual processes employed during transition of academic years, timing of review and misinterpr...
Incorrect Pell Calculations Planned Corrective Action: Management acknowledges the error in calculation. As a result of change in student information software and financial aid software in conjunction with manual processes employed during transition of academic years, timing of review and misinterpretation of Summer Pell regulations, this error was not identified timely. This may have carried over to the subsequent term. Management receives this as opportunity to improve upon processes to ensure higher visibility and oversight to reduce any further risk making certain to align policies with DOE. Person Responsible for Corrective Action Plan: Kristina Elmore, Director of Financial Aid Anticipated Date of Completion: February 2026
U.S. Department of Education Coastal Carolina University respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit Period: July 1, 2024 - June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are number...
U.S. Department of Education Coastal Carolina University respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit Period: July 1, 2024 - June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FINANCIAL STATEMENT AUDIT None noted FINDINGS - FEDERAL AWARD PROGRAMS AUDITS Department of Education 2025-001 National Student Loan Data System (NSLDS) Reporting Recommendation: We recommend the University review and update its policies and procedures to ensure all enrollment status changes are reviewed and submitted in a timely manner in accordance with federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Plan: The University reviewed its reporting procedures for enrollment changes occurring after initial term reporting and implemented procedural changes to ensure timely updates. Anticipated Completion Date: Corrective action occurred prior to June 30, 2025. Name of Contact Person Responsible for the Corrective Action Plan: Stacy Wyeth, Registrar
The City remains committed to complying with Uniform Guidance requirements and acknowledges the importance of strengthening internal controls related to the inspection process. To support this effort, a centralized tracking system will be implemented to monitor inspection deadlines for all HOME-assi...
The City remains committed to complying with Uniform Guidance requirements and acknowledges the importance of strengthening internal controls related to the inspection process. To support this effort, a centralized tracking system will be implemented to monitor inspection deadlines for all HOME-assisted rental units. The City will also enhance its policies and procedures to clearly define staff responsibilities, inspection scheduling protocols, documentation standards, and required follow-up actions for units found to be out of compliance. Expected Completion: June 30, 2026 Responsible Contact Person: Michael Cannizzaro, Commissioner of Finance, 315-448-8323
Contact Person: Jeremy Teetor, Chief Financial Officer Corrective Action Plan: The finding resulted primarily from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely bas...
Contact Person: Jeremy Teetor, Chief Financial Officer Corrective Action Plan: The finding resulted primarily from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. The Finance department will also strive to keep key positions filled at all times and ensure that staff receives appropriate training regarding reconciliations. Proposed Completetion Date: Immediately
The District has identified the issue and confirmed that enrollment records are now populating with the correct withdrawal dates. Moving forward, we will collaborate with Financial Aid and IT to implement a validation process. As part of this process, a sample of 20 students will be tested each repo...
The District has identified the issue and confirmed that enrollment records are now populating with the correct withdrawal dates. Moving forward, we will collaborate with Financial Aid and IT to implement a validation process. As part of this process, a sample of 20 students will be tested each reporting cycle to verify that dates reported to the National Student Clearinghouse (NSC) are accurately reflected in the National Student Loan Data System (NSLDS). To ensure continued compliance, the District will establish a new Enrollment Reporting Workgroup that will meet once per semester, following the submission of the second NSC report. This workgroup will review results of the sample testing, monitor reporting accuracy, and address any discrepancies promptly.
Recommendation: We recommend that the University establish procedures to ensure that FISAP is accurately presented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: National University (NU) agrees with the importanc...
Recommendation: We recommend that the University establish procedures to ensure that FISAP is accurately presented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: National University (NU) agrees with the importance of ensuring the accuracy of its data reported in the FISAP. The University will take the following steps to resolve the issue. NU identified a knowledge gap for the tuition and fees reporting required on the FISAP. Training will be conducted to review the requirements for reporting tuition and fees at the Undergraduate and Graduate levels, which are fully reconciled to the audited financial statements. In addition to the training, the University has implemented a secondary review of the calculation, which will be completed by the University controller prior to submission. Name(s) of the contact person(s) responsible for corrective action: - Robert Conlon, AVP Financial Aid Compliance - Christina Nowacki, Controller Planned completion date for corrective action plan: December 2025
Recommendation: We recommend that the University establish procedures to ensure that at least 7% of Federal Work Study allocation is used for community service jobs, including a reading tutor, or successfully receive a waiver. Explanation of disagreement with audit finding: There is no disagreement ...
Recommendation: We recommend that the University establish procedures to ensure that at least 7% of Federal Work Study allocation is used for community service jobs, including a reading tutor, or successfully receive a waiver. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: National University (NU) agrees with the importance of ensuring compliance with FWS community service requirements. The University implemented additional internal controls and policy changes to how it administers the FWS program and completes FISAP reporting to resolve this issue. During NU’s annual FISAP reporting process, it discovered that it had not met its FWS community service obligation. The University submitted a waiver, but it was denied. The University took immediate action to determine the cause of not meeting its FWS community service obligations. Community Partnership Management: National University previously had a partnership with Barrio Logan College Institute (BLCI) located in San Diego, CA. This partnership changed during the pandemic when all schools received a waiver for the community service requirement. In August 2024, Elyse Joiner, Director of Financial Aid Processing, again reached out to BLCI to reestablish a partnership. At that time, National was informed that the previous point of contact was no longer employed with BLCI, but the institute was still interested in partnering with National to meet the community service requirement for Federal Work Study. Ms. Joiner had several communications with BLCI to implement and finalize the setup of the reading and math tutors, with the only outstanding item related to the need for a virtual option. Unfortunately, communication between National University and BLCI ceased in April 2025 when National stopped receiving responses from BLCI to its inquiries. To establish another partnership, Ms. Joiner reached out to United Way of San Diego County to explore the possibility of establishing a reading or math tutor program with them but did not receive a response. Program Administration Change: Federal Work Study funds were budgeted to meet the University’s community service requirement; however, due to unforeseen circumstances and the efforts noted above, the University was unable to meet the 7% community service requirement. The University did have tutors available to the University community, but this did not fulfill the community service requirement. National University has since rectified this for the current aid year. The positions have been posted (R 2025 3051), and the University will have multiple FWS students at the Nest at Spectrum, offering tutoring services to both NU students and the public. The YMCA next to Spectrum will also be informed about the services to promote additional awareness within the local community. Additional opportunities are being actively explored within the Student Disability Services team and the Schools of Law & Public Service and Education. Steps taken to improve transparency and tracking: The University conducted a holistic review of the current FWS policies and procedures and has or will take the following steps: o Comprehensive training for administering the FWS program and Campus-Based Funding programs o Develop and implement an internal control plan that monitors FWS spending activity, allowing for the proactive identification of when the University should reallocate funds between campus-based programs. o Implemented quarterly calibration meetings between FWS/Operations leaders and HR to ensure its FWS program is on track to meet the FWS community service, literacy, and tutoring regulatory requirements. o Explore the expansion of community service relationships and opportunities within the Federal Work Study Program. Name(s) of the contact person(s) responsible for corrective action: - Alan Coddington, AVP Student Financial Services - Elyse Joiner, Director of Operations, Financial Aid Processing and Technical Solutions - Rob Conlon, AVP Financial Aid Compliance Planned completion date for corrective action plan: February 2026
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