Corrective Action Plans

Finding 1201508 (2025-003)

Material Weakness 2025

Volunteers of America Western Washington and Subsidiary

WA

Allowable Costs / Cost Principles § 200.303

2025-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles We acknowledge BDO’s finding regarding an unallowable cost that was initially charged to the Home Investment Partnerships Program. Although the error was able to be rectified, the initial error indicated that internal controls...

2025-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles We acknowledge BDO’s finding regarding an unallowable cost that was initially charged to the Home Investment Partnerships Program. Although the error was able to be rectified, the initial error indicated that internal controls did not prevent or detect the unallowable charge at the time of posting. To strengthen internal controls over allowable costs and ensure expenditures charged to federal programs comply with Uniform Guidance and program-specific requirements, VOAWW will implement the following corrective actions: Strengthened Review of Allowable Costs Before the end of FY26, the Finance Department will enhance its invoice review procedures for all programs. This strengthened review will include verification of: • Allowability under 2 CFR §200 Subpart E • Program specific requirements • Contract terms and approved budgets • Supporting documentation for each cost Review steps will be documented to ensure a clear audit trail. Training for Staff on Federal Allowable Cost Requirements Beginning in FY26, Finance, Grants, and Contract Compliance staff responsible for coding, approving, or reviewing federal expenditures will receive training on: • Allowable cost principles under 2 CFR §200.403–.405 • Program specific cost restrictions • Documentation standards • The importance of internal controls over federal expenditures Before the end of FY26, VOAWW will implement internal controls to ensure that allowability determinations are made internally by trained staff prior to charging costs to federal awards. Centralized Federal Award Compliance Reference By the end of FY26, Contract Compliance will maintain a centralized compliance reference for all federal programs, including allowability rules, program specific restrictions, and documentation requirements. Finance staff will reference this tool during invoice review to ensure consistent application of federal requirements. These corrective actions will strengthen VOAWW’s internal controls over allowable costs, reduce the risk of unallowable expenditures being charged to federal programs, and ensure compliance with Uniform Guidance and HUD program requirements. Responsible Individual: Claire Danielson, VIP of Finance Estimated Completion Date: June 30, 2026

View Audit 396088

Finding 1201506 (2025-002)

Material Weakness 2025

Volunteers of America Western Washington and Subsidiary

WA

Reporting Allowable Costs / Cost Principles § 200.303 § 200.403

2025-002 Accounts Payable Cutoff We acknowledge BDO’s inquiry regarding an invoice that appeared to relate to the prior fiscal period. The invoice was received after Accounts Payable closed without advance notification for accrual. BDO noted a similar issue in an additional sample. To strengthen our...

2025-002 Accounts Payable Cutoff We acknowledge BDO’s inquiry regarding an invoice that appeared to relate to the prior fiscal period. The invoice was received after Accounts Payable closed without advance notification for accrual. BDO noted a similar issue in an additional sample. To strengthen our accounts payable cutoff controls and prevent similar issues, we will implement the following improvement measures: • Formalize the Accrual Process – While an accrual process already exists, before the end of FY26, we will document and strengthen the accrual procedures by requiring Program Managers to notify Finance, specifically the AP team inbox, when work from a vendor has been completed, but an invoice has not yet been received, on an annual basis by a given deadline. This will ensure that known obligations are captured in the correct fiscal period. • Strengthen Review of Post-Year-End Invoices – While regular review of invoices is already a part of our regular AP process, Accounts Payable will implement a more stringent review process before the end of FY26 for all invoices received in the first period after fiscal year end, including verification of service dates, contract terms, and deliverables. • Enhanced Communication Expectations – Program Managers will receive training and guidance before the end of FY26 on the importance of timely invoice submission and the need to alert Finance when delays occur. • Documentation of Cutoff Decisions – For invoices received after close, before the end of FY26, Accounts Payable will document the receipt date, supporting details, and rationale for the period in which the expense is recorded to maintain a clear audit trail. These improvements will strengthen our internal controls over AP cutoff, improve the consistency of accrual practices, and reduce the risk of misstatements due to late or ambiguous invoices. Responsible Individual: Claire Danielson, VIP of Finance Estimated Completion Date: June 30, 2026

View Audit 396088

Finding 1201504 (2025-001)

Material Weakness 2025

Hardee County District School Board

FL

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility

The District appreciates the opportunity to respond to the audit finding regarding inconsistencies between Title I rank order and the allocation of funds based on low-income student percentages for the 2024-2025 fiscal year. Our review indicates that the variance in allocations resulted from a budge...

The District appreciates the opportunity to respond to the audit finding regarding inconsistencies between Title I rank order and the allocation of funds based on low-income student percentages for the 2024-2025 fiscal year. Our review indicates that the variance in allocations resulted from a budget decision to provide additional Title I funding to Bowling Green Elementary to support after-school programming, without fully accounting for per-pupil allocation. Historically, Bowling Green Elementary has served one of the highest concentrations of students from low-income families in the District, and the additional allocation was intended to ensure continuity of extended learning opportunities for students with significant academic need. While this decision was grounded in student need, the District recognizes that the additional funds were not fully reconciled with updated poverty data and required rank-order calculations. The District has demonstrated compliance with rank and serve requirements in prior years; however, to prevent recurrence, we are strengthening our internal controls. Beginning immediately, the District will implement a structured monthly review of Title I school allocations involving the Title I Program Specialist, the Finance Director, and the Deputy Superintendent to ensure that the 2025-2026 allocations align with current poverty data and PSES calculations. Additionally, the District will seek guidance from the Florida Department of Education Title I Office to confirm that our procedures fully meet all regulatory expectations. The District is confident that these corrective actions will ensure full compliance in 2025-2026 moving forward and will strengthen the integrity of our allocation processes.

View Audit 396085

Finding 1201503 (2025-001)

Material Weakness 2025

City of Newton, Massachusetts

MA

Cash Management Reporting School Nutrition Programs

Child Nutrition Cluster, ALN’s 10.553 & 10.555 Recommendation: We recommend the review and approval process over monthly claims for reimbursement be strengthened to enhance the prevention of discrepancies between the claim for reimbursement and underlying data. Explanation of disagreement with audit...

Child Nutrition Cluster, ALN’s 10.553 & 10.555 Recommendation: We recommend the review and approval process over monthly claims for reimbursement be strengthened to enhance the prevention of discrepancies between the claim for reimbursement and underlying data. Explanation of disagreement with audit finding: Management agrees with the finding. Action taken in response to finding: Newton operated the National School Lunch Program (NSLP) during the Extended School Year (ESY) for the first time during the summer 2024, which created a reporting challenge. Students from across the district's 23 schools attended ESY in seven (7) schools/sites, but their school-year home schools could not be changed in the Student Information System (Aspen). Therefore, student meal counts reported to their home school on the FP9 but had to be reported on the DESE School Report for the ESY school/site they attended. Given the system interface complexities, some counts had to be manually entered, for which two (2) meal counts were incorrectly entered for breakfast versus lunch. Given that the district did not operate the School Breakfast Program (SBP) and did not serve breakfast, these two (2) manual errors were counted as lunch counts when entered for the School Report. The total meal count did match on the FP9 and School Report. For this inconsistency, the correct action should have been to manually update these two counts in the Point of Sale system (Mosaic) so that the two breakfast counts reflected correctly as lunch counts. Name(s) of the contact person(s) responsible for corrective action: Amy Mistrot, NPS Director of Business Operations. Planned completion date for corrective action plan: Newton was able to set conditional parameters in Aspen for ESY 2025 so that the student meal counts reported to their ESY school/site versus their home school, so this reporting issue was corrected the following summer.

View Audit 396079

Finding 1201500 (2025-001)

Material Weakness 2025

North Central Behavioral Health Systems, Inc.

IL

Allowable Costs / Cost Principles

Finding 2025-001 Criteria: The Organization should have controls in place over payroll related expenditures to ensure appropriate allocation between federal award programs and the relevant approval should be retained. Condition: Documented review of employee time-cards was not retained for an employ...

Finding 2025-001 Criteria: The Organization should have controls in place over payroll related expenditures to ensure appropriate allocation between federal award programs and the relevant approval should be retained. Condition: Documented review of employee time-cards was not retained for an employee selected for testing. Additionally, the documentation of review of the allocation between federal award programs was not retained by the Organization for the remaining employees selected for testing. Cause: The controls in place were not sufficiently documented to support their occurrence. Effect: Employee time was allocated to the corresponding major program without retaining sufficient documentation of review. Questioned Costs: There were no questioned costs identified. Context: A sample of 40 employee time-cards was tested. One time-card did not have documentation of review retained. The remaining 39 time-cards did not have documented review of the allocation between federal award programs. Recommendation: We recommend that management review the existing policies and procedures in place over personnel time and allocation and ensure that sufficient reviews are occurring and the corresponding documentation of the reviews are obtained. Anticipated completion date – Resolved in 2026 Corrective Action: Management agrees with the finding. NCBHS implemented policies and procedures to ensure accurate, timely, and compliant reporting of personnel effort charged to State of Illinois grants (including IDHS) and all Federal awards. The policy ensures the agency meets the requirements under 2 CFR 200.430(i) for Federal awards and applicable State grant accountability standards.

View Audit 396075

Finding 1201499 (2025-004)

Material Weakness 2025

Town of Batesburg-Leesville

SC

Reporting § 200.502 § 200.510

The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Fi...

The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Finance staff will also create new line items to ensure separation of grants from other special revenue. Additionally, the Town will reflect Retainage Payable on balance sheets. The estimated completion date is June 1, 2026. Jay Hendrix, Town Manager, is responsible for overseeing the corrective action plan and that implementation occurs by the estimated completion date.

View Audit 396071

Finding 1201498 (2025-003)

Material Weakness 2025

Town of Batesburg-Leesville

SC

Reporting § 200.502 § 200.510

The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Fi...

The Town will ensure that all grant funds are accounted for in the proper budget year, to include revenue and expenses. This will involve Finance staff and the grant manager for each grant noting the proper budget year on invoices and revenue receipts. A label will be created to note these items. Finance staff will also create new line items to ensure separation of grants from other special revenue. Additionally, the Town will reflect Retainage Payable on balance sheets. The estimated completion date is June 1, 2026. Jay Hendrix, Town Manager, is responsible for overseeing the corrective action plan and that implementation occurs by the estimated completion date.

View Audit 396071

Finding 1201497 (2025-001)

Material Weakness 2025

National Governors Association Center for Best Practices

DC

Procurement, Suspension & Debarment § 200.213 § 200.318

Jordan Kramer Chief Financial Officer 202-624-7787 January 2024 Management's Corrective Action Plan: NGA has previously developed and communicated our procurement processes and procedures to all staff members. We will provide additional training for employees involved in sourcing decisions during me...

Jordan Kramer Chief Financial Officer 202-624-7787 January 2024 Management's Corrective Action Plan: NGA has previously developed and communicated our procurement processes and procedures to all staff members. We will provide additional training for employees involved in sourcing decisions during meetings, focusing on the accurate documentation of decision-making processes. In response to this finding, NGA will review the vendor selection processes for events over the past six months to ensure appropriate documentation is captured in the finance system. Ongoing training will be provided to new program staff regarding procurement documentation requirements to maintain compliance with established policies. When circumstances necessitate working with a specific entity or time constraints preclude a competitive process, program leaders and finance will collaborate to produce a memorandum detailing the work’s unique requirements and the criteria underlying vendor selection. Additionally, the CFO will coordinate with management to notify supervisors when procedures are not followed and to pursue corrective actions, ensuring all individuals complete the necessary compliance steps. The NGA Management Team deeply values the partnership with its Baker Tilly auditors as we address these concerns. Your expertise and guidance are crucial to our improvement process. Please ask any questions or provide feedback on management's action plans.

View Audit 396069

Finding 1201496 (2025-004)

Material Weakness 2025

Lewistown Community Unit Schools District 97

IL

Cash Management Reporting

Condition: The District's expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Management will review all expenditure reports. Only expenditures obligated within the grant period wi...

Condition: The District's expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Management will review all expenditure reports. Only expenditures obligated within the grant period will be included on the expenditure report. Any obligations not yet liquidated will be reported as such.

View Audit 396063

Finding 1201495 (2025-003)

Material Weakness 2025

Lewistown Community Unit Schools District 97

IL

Internal Control / Segregation of Duties Reporting § 200.303

Condition: Multiple individuals are responsible for the preparation and submission of the District's quarterly exepnditure reports; however, the expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of t...

Condition: Multiple individuals are responsible for the preparation and submission of the District's quarterly exepnditure reports; however, the expenditure reports filed for September 30, 2024 included expenditures in the amount of $22,040 that were neither obligated nor liquidated by the date of the report. Plan: Mannagement will review all expenditure reports. Only expenditures obligated within the grant period will be included on the expenditure report. Any obligations not yet liquidated will be reported as such.

View Audit 396063

Finding 1201494 (2025-002)

Material Weakness 2025

Lewistown Community Unit Schools District 97

IL

Procurement, Suspension & Debarment

Condition: The District did not obtain debarment certification or document their vendor search in the System for Award Management website for vendors contracted in excess of $25,000 related to the grant program. Upon further review, it was determined that the vendors were not suspended or debarred. ...

Condition: The District did not obtain debarment certification or document their vendor search in the System for Award Management website for vendors contracted in excess of $25,000 related to the grant program. Upon further review, it was determined that the vendors were not suspended or debarred. Plan: Procedures need to be implemented to ensure all vendors contracted with have not been suspended or debarred or otherwise excluded from doing business, prior to procuring their services.

View Audit 396063

Finding 1201487 (2025-010)

Material Weakness 2025

William Peace Universirty

NC

Student Financial Aid Internal Control / Segregation of Duties Material Weakness § 200.303

Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. ...

Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. Additionally, ongoing training should be provided to financial aid staff on the importance of internal controls and compliance with Title IV regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review its staffing and the need for separation of duties as part of an effective internal control system and take appropriate actions.. Name(s) of the contact person(s) responsible for corrective action: Vice President for Enrollment Management Damon Wade, Director of Financial Aid Deniesha Newby, and Controller Will Gibbons Planned completion date for corrective action plan: June 30, 2026

View Audit 396041

Finding 1201483 (2025-009)

Material Weakness 2025

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Credit Balance Recommendation: We recommend the University evaluate its procedures and policies around credit balances to ensure that students are refunded within the fourteen day requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action tak...

Credit Balance Recommendation: We recommend the University evaluate its procedures and policies around credit balances to ensure that students are refunded within the fourteen day requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management understands this federal requirement and will ensure that it is met. Name(s) of the contact person(s) responsible for corrective action: Controller Will Gibbons Planned completion date for corrective action plan: June 30, 2026

View Audit 396041

Finding 1201479 (2025-008)

Material Weakness 2025

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Direct Loan Reconciliations Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a process to maintain all reconciliations as su...

Direct Loan Reconciliations Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a process to maintain all reconciliations as support of performance monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will take action to ensure compliance with this recommendation.. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby Planned completion date for corrective action plan: June 30, 2026

View Audit 396041

Finding 1201478 (2025-007)

Material Weakness 2025

William Peace Universirty

NC

Student Financial Aid Reporting Significant Deficiency

Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreem...

Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that its policies and procedures are reviewed and updated to ensure compliance with this recommendation. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby Planned completion date for corrective action plan: June 30, 2026

View Audit 396041

Finding 1201476 (2025-006)

Material Weakness 2025

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Direct Loan Overaward Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in res...

Direct Loan Overaward Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review existing procedures and modify as needed to ensure compliance with this recommendation.. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby Planned completion date for corrective action plan: June 30, 2026

View Audit 396041

Finding 1201475 (2025-005)

Material Weakness 2025

William Peace Universirty

NC

Reporting Student Financial Aid Significant Deficiency

National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with au...

National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review regulations to ensure that staff understands reporting requirements of the NSLDS. Name(s) of the contact person(s) responsible for corrective action: Financial Aid Director Deniesha Newby Planned completion date for corrective action plan: June 30, 2026

View Audit 396041

Finding 1201473 (2025-004)

Material Weakness 2025

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Return of Title IV (R2T4) Funds Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation of disagreement with audit finding: There is no disagreement ...

Return of Title IV (R2T4) Funds Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will take action to comply with this recommendation. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby

View Audit 396041

Finding 1201469 (2025-001)

Material Weakness 2025

Maranatha Baptist University

WI

Student Financial Aid Eligibility Significant Deficiency

U.S. Department of Education Maranatha Baptist University (the University) respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 01, 2024 to June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The...

U.S. Department of Education Maranatha Baptist University (the University) respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 01, 2024 to 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 Our audit did not disclose any matters required to be reported in accordance with Government Auditing Standards. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2025-001 Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063 & 84.268 Recommendation: We recommend that the University maintain documentation of both formal and informal award notifications in their financial aid software to ensure all necessary communications are made. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University Financial Aid Office will add a step in the awarding process to verify that award emails are sent and are documented in the system. Name of the contact person responsible for corrective action: Donald Donovan, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2026 *** If the U.S Department of Education has questions regarding this plan, please call Donald Donovan, Chief Financial Officer, at 920-206-2314.

View Audit 396040

Finding 1201466 (2025-001)

Material Weakness 2025

Scripps Health and Affiliates

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended Se...

Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2025 Finding Reference Number: 2025-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of payroll expenditures to support activities allowed or unallowed and allowable costs/cost principles related to payroll expenditures reimbursed for the project worksheet. Corrective Action Plan: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late fiscal year 2022 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: revised the timekeeping policy to clarify employee and manager responsibilities, modified “failure to comply” provisions, deployed educational programs for both management and staff, reviewed/improved Kronos and UKG Pro Time and Attendance system automated notifications, and training resources have been available to management and staff via our Scripps intranet site. Leadership monitors policy compliance by individual employee and managers via systemwide reporting on a biweekly basis. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: Completed in fiscal year 2022. As the expenditures in the project worksheet were incurred from the beginning of the COVID-19 pandemic, the corrective action plan put in place during 2022 could not previously remediate the project; however, all payroll expenditures incurred after the end of fiscal year 2022 have these corrective actions in place.

View Audit 396036

Finding 1201465 (2025-001)

Material Weakness 2025

Rockingham County

NC

Eligibility Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Section III – Federal Award Findings and Questioned Costs All identified cases are being reviewed and corrected to ensure compliance. Supervisors will conduc...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Section III – Federal Award Findings and Questioned Costs All identified cases are being reviewed and corrected to ensure compliance. Supervisors will conduct targeted refresher training on income and resource calculation, SSI termination procedures, and redetermination timeliness and procedures. Regular quality assurance reviews and staff support will continue to ensure sustained compliance and improved accuracy in case processing. Training will be completed by December 15, 2025. Corrective actions for finding 2025-001 also apply to the State Awards findings. Section IV – State Award Findings and Questioned Costs Lisa Chaney, Nicole Victory and Debbie McGuire - Medicaid Supervisors; Mandy Edwards - Medicaid Manager 189

View Audit 396035

Finding 1201464 (2025-003)

Material Weakness 2025

Hertford County

NC

Eligibility Internal Control / Segregation of Duties Material Weakness

Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the Cou...

Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the County will strengthen internal controls related to eligibility determinations by implementing a comprehensive, county-wide corrective action strategy focused on staff competency, supervisory oversight, and process standardization. First, the County will enhance training for all staff involved in Medicaid eligibility determinations. This training will reinforce program requirements and applicable State Medicaid manuals, with specific emphasis on income and resource verification, household composition, timely requests for information, redetermination timeframes, and proper handling of SSI terminations. Refresher trainings will be conducted regularly, and training materials will be updated to reflect current policy and procedural changes. Second, the County will formalize and strengthen its internal case review and quality assurance processes. Supervisory reviews will be conducted routinely to ensure eligibility determinations are accurate, complete, and compliant with federal and state guidelines. Identified errors will be documented, corrected timely, and used as coaching opportunities to prevent recurrence. Management will monitor trends in errors to assess effectiveness of corrective actions and adjust oversight efforts as needed. Anetre Vaughan, Adult Medicaid Supervisor and Jacqueline Boyd, Family and Children's Medicaid Supervisor Section III - Federal Award Findings and Question Costs BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 116

View Audit 396031

Finding 1201463 (2025-002)

Material Weakness 2025

Day Spring Baxter

KY

HUD Housing Programs

Recommendation: The design of the current internal controls should be reviewed to ensure tenant files are complete and accurate. The information in the files should support the data used in preparing the Form 50059, and procedures for calculating income using HUD guidelines should be reviewed. The i...

Recommendation: The design of the current internal controls should be reviewed to ensure tenant files are complete and accurate. The information in the files should support the data used in preparing the Form 50059, and procedures for calculating income using HUD guidelines should be reviewed. The information in the files should also support that proper eligibility screening procedures have been completed, and updated lease agreements should be obtained for any tenant whose lease is not the correct model lease document. A corrected Form 50059 should be prepared to correct the tenant income discrepancy noted in the audit, and the required adjustment processed through the HUD voucher. In addition, management should review all files and report any additional discrepancies to HUD in a timely manner. Action Taken: Day Spring Baxter Avenue, Inc. will review all tenant files and report any discrepancies in calculated tenant rent and rental subsidy to HUD and make the necessary adjustments on the 50059 forms as soon as possible. Tenant files will be reviewed to ensure proper documentation is maintained and the proper model lease is being used.

View Audit 396030

Finding 1201461 (2025-001)

Material Weakness 2025

Edgewood College, Inc.

WI

Special Tests & Provisions Student Financial Aid Reporting

Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We fou...

Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We found another instance of a student’s information not reported timely, however management did eventually detect and correct the error outside the required timeframe. Corrective Action planned: Management agrees and has implemented necessary procedures/controls to ensure the College is in compliance with enrollment requirements. Management has corrected the student’s change status not previously reported. Name(s) of Contact Person(s) Responsible for Corrective Action: {Jennifer Young, Director of Financial Aid and Edgewood Central, and Katelyn Peters, Student Service Specialist.} Anticipated Completion Date: Has already began as of the audit. Staff turnover occurred, have replaced the Student Service Specialist position - now have second point on NSC reporting.

View Audit 396008

Finding 1201455 (2025-001)

Material Weakness 2025

New York Law School

NY

Student Financial Aid

Finding No. 2025-001 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The School agrees with the finding. The Registrar will work with Ellucian to update reporting process to National Student Clearinghouse to include ...

Finding No. 2025-001 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The School agrees with the finding. The Registrar will work with Ellucian to update reporting process to National Student Clearinghouse to include the two program lengths for same CIP code. Anticipated Completion Date: Our expected remediation date is June 15, 2026. If we are unable to remediate by June 15, 2026, we will correct enrollment reporting to reflect accurate program length by September 1, 2026. Person(s) Responsible for Corrective Action: Michelle T. Weller Registrar 212-431-2300

View Audit 396004

Corrective Action Plans

Filters