Finding 1181773 (2025-004)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-20
Audit: 393057
Organization: Manor College (PA)
Auditor: SMITH+HOWARD PC

AI Summary

  • Core Issue: The College has not fully developed or documented its information security program as required by the FTC Safeguards Rule, leading to potential risks for student information.
  • Impacted Requirements: Key components such as a written risk assessment, formal security program, incident response policy, and vendor oversight are incomplete or informal.
  • Recommended Follow-Up: Complete and approve the risk assessment, finalize the security program, establish a testing protocol, implement the incident response policy, and ensure vendor contracts meet safeguard requirements.

Finding Text

Federal Program: Student Financial Aid Cluster Type of Finding: Significant Deficiency in Internal Control Over Compliance and Other Matters Federal Agency: Department of Education ALN Number: 84.063, 84.268, 84.033, 84.007 Criteria: The FTC Safeguards Rule, 16 CFR 314.4, requires covered financial institutions to develop, implement, and maintain a comprehensive information security program that includes, at a minimum:  Designation of a qualified individual to oversee the program  A written risk assessment addressing internal and external threats  Implementation of safeguards designed to control identified risks, with regular testing or monitoring  Formal oversight of service providers, including contractual safeguard requirements  Ongoing evaluation and adjustment of the information security program Condition: The College has not fully developed, implemented, and documented the information security program required under the Federal Trade Commission’s Safeguards Rule, 16 CFR 314.4. While the College has implemented certain administrative and technical security measures, several required components remain informal, incomplete, or in draft status. Specifically:  The College has not completed a written risk assessment that identifies reasonably foreseeable internal and external risks, defines evaluation and categorization criteria, assesses the confidentiality, integrity, and availability of customer information, and documents risk mitigation or acceptance decisions, as required by § 314.4(b).  The College has not formally adopted a written information security program that is based on the results of a documented risk assessment and includes a defined program for regular testing and monitoring of key controls, systems, and procedures, as required by § 314.4(c).  Incident response and testing activities are described as informal or in draft form, and a finalized incident response policy has not yet been approved and implemented.  Vendor oversight procedures are not fully documented to demonstrate that all service providers are contractually required to maintain safeguards consistent with the Safeguards Rule, as required by § 314.4(d). As a result, required elements of the Safeguards Rule are planned or in progress, but not fully implemented. Cause: Management has focused primarily on deploying technical security controls and initiating program development activities; however, formal governance documentation, risk assessment methodology, and program approval processes have not progressed at the same pace. As a result, the information security program has not been fully documented or formally implemented in accordance with regulatory requirements. Context and Effect: Failure to fully comply with 16 CFR 314.4 increases the risk that student information may not be adequately protected against unauthorized access, disclosure, or misuse. In addition, noncompliance with the FTC Safeguards Rule exposes the College to potential regulatory scrutiny, enforcement actions, and penalties, as well as reputational harm in the event of a cybersecurity incident. Questioned costs: None. Recommendation: The College should: 1. Complete and formally approve a written risk assessment that meets all requirements of 16 CFR 314.4(b). 2. Finalize, adopt, and implement a written information security program aligned with the documented risk assessment. 3. Establish and document a formal testing and monitoring program with defined scope and frequency. 4. Finalize and implement the incident response policy and ensure it is integrated into the broader information security program. 5. Review service provider contracts and document that all applicable vendors are required by contract to maintain appropriate safeguards. Grantee Comment: Refer to Corrective Action Plan.

Corrective Action Plan

Management has developed a written information security program to comply with the FTC Safeguards Rule. The program documents administrative, technical, and physical safeguards designed to protect customer information and assigns responsibility for oversight and monitoring.

Categories

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency

Other Findings in this Audit

  • 1181761 2025-002
    Material Weakness Repeat
  • 1181762 2025-003
    Material Weakness Repeat
  • 1181763 2025-004
    Material Weakness Repeat
  • 1181764 2025-002
    Material Weakness Repeat
  • 1181765 2025-003
    Material Weakness Repeat
  • 1181766 2025-004
    Material Weakness Repeat
  • 1181767 2025-005
    Material Weakness Repeat
  • 1181768 2025-002
    Material Weakness Repeat
  • 1181769 2025-003
    Material Weakness Repeat
  • 1181770 2025-004
    Material Weakness Repeat
  • 1181771 2025-002
    Material Weakness Repeat
  • 1181772 2025-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
84.268 FEDERAL DIRECT STUDENT LOANS $2.95M
84.063 FEDERAL PELL GRANT PROGRAM $1.81M
84.116 FUND FOR THE IMPROVEMENT OF POSTSECONDARY EDUCATION $543,612
84.031 HIGHER EDUCATION INSTITUTIONAL AID $371,142
84.007 FEDERAL SUPPLEMENTAL EDUCATIONAL OPPORTUNITY GRANTS $42,730
84.033 FEDERAL WORK-STUDY PROGRAM $31,123