Finding 366598 (2023-001)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2023
Accepted
2024-02-08
Audit: 289452
Organization: Spalding University (KY)
Auditor: Dean Dorton

AI Summary

  • Core Issue: The University failed to conduct a required GLBA compliance risk assessment in the last fiscal year, leading to noncompliance with federal regulations.
  • Impacted Requirements: Key GLBA components, such as risk assessment, data inventory, encryption, app assessment, and multi-factor authentication, were not adequately documented or implemented.
  • Recommended Follow-Up: Conduct an annual IT risk assessment, report the Information Security Program status to the Board of Trustees, and update policies to ensure GLBA compliance.

Finding Text

Finding 2023-001 Federal Program: U.S. Department of Education - Student Financial Aid Cluster: Federal Pell Grant, 84.063 Federal Supplemental Education Opportunity Grant, 84.007 Federal Work Study Program, 84.033 Federal Perkins Loan Program, 84.038 Federal Direct Loan Program, 84.268 Nursing Student Loan Program, 93.364 Scholarships for Disadvantaged Students, 93.925 Criteria: The University is required to comply with the Gramm-Leach-Bliley Act (GLBA) section 16 CFR 314.4(b). Condition: During our audit procedures, we noted that a GLBA compliance risk assessment was not performed within the last fiscal year. Various vulnerability assessments have been conducted since 2020, however updated GLBA compliance guidance has more specific requirements for what must be performed as part of an IT risk assessment in order to identify reasonable, foreseeable internal and external risks to the security, confidentiality, and integrity of student information that addresses the following areas: a. Information systems, including network and software design, as well as information processing, storage, transmission and disposal. b. Detecting, preventing and responding to attacks, intrusions, or other systems failures. c. Documented safeguards for each identified risk. d. Appropriate mitigated risk levels for each identified risk. Updated GLBA guidance requires that a Qualified Individual who oversees the Information Security Program makes a written report to the Board of Trustees on the status of the Information Security Program at least annually. Lastly, in reviewing the University's Information Security Program and IT policies, it was noted that four attributes were not appropriately documented for GLBA compliance: a. Conduct a periodic inventory of data, noting where its collected, stored, or transmitted. b. Encrypt customer information on the University's system and when it's in transit. c. Assess apps developed by the University. d. Implement multi-factor authentication for anyone accessing customer information on the University's system. Cause: The University did not have controls in place to ensure all GLBA requirements were met. Effect: The University is not in compliance with GLBA requirements. Recommendation: We recommend the following to ensure compliance with GLBA requirements: a. The University conduct an annual IT risk assessment that includes all components required by GLBA and periodically update the Information Security Program in response to identified risks. b. Ensure the status of the University's Information Security Program is reported, in writing, to the Board of Trustees at least annually and that the Qualified Individual signs off on this report. c. Update the policy library to ensure that the policies are appropriately documented to reduce the risk of GLBA noncompliance. Views of responsible officials and planned corrective actions: The University agrees that GLBA requirements are to be implemented and has taken steps to change the process. See corrective action plan.

Corrective Action Plan

Criteria: The University is required to comply with the Gramm-Leach-Bliley Act (GLBA) section 16 CFR 314.4(b). Condition: A GLBA compliance risk assessment was not performed within the last fiscal year. Various vulnerability assessments have been conducted since 2020, however updated GLBA compliance guidance has more specific requirements for what must be performed as part of an IT risk assessment in order to identify reasonable, foreseeable internal and external risks to the security, confidentiality, and integrity of student information that addresses the following areas: a. Information systems, including network and software design, as well as information processing, storage, transmission and disposal. b. Detecting, preventing and responding to attacks, intrusions, or other systems failures. c. Documented safeguards for each identified risk. d. Appropriate mitigated risk levels for each identified risk. Updated GLBA guidance requires that a Qualified Individual who oversees the Information Security Program makes a written report to the Board of Trustees on the status of the Information Security Program at least annually. The University's Information Security Program and IT policies has four attributes that were not appropriately documented for GLBA compliance: a. Conduct a periodic inventory of data, noting where its collected, stored, or transmitted. b. Encrypt customer information on the University's system and when it's in transit. c. Assess apps developed by the University. d. Implement multi-factor authentication for anyone accessing customer information on the University's system. Cause: The University did not have controls in place to ensure all GLBA requirements were met. Effect: The University is not in compliance with GLBA requirements. Corrective Actions Taken or Planned: Items that have been resolved: a. Customer data, and backups of customer data, is now encrypted at rest and in transit. b. All users with access to customer data are required to use multi-factor authentication.c. The University password policy has been updated to strengthen passwords and increase minimum length to 12 characters with complexity. The University has also implemented a tool to block the reuse of compromised passwords from the HIBP database. Items to be resolved: a. An update on the University’s information security program draft has been shared with the Board of Trustees and a final report will be issued by February 1, 2024. b. The University has begun an inventory of customer data and systems storing customer data. The University does not have any University developed apps that handle or store customer data (this will be documented in the customer data inventory). This inventory will be completed by April 15, 2024. c. The University is evaluating proposals for an assessment to include a risk assessment and internal and external vulnerability scans. The IT risk assessment is planned to be completed by June 1, 2024. d. Updated GLBA policies, including a disaster recovery policy, will be completed by June 1, 2024 Person Responsible for Implementing Correction Action: Ezra Krumhansl, Chief Financial Officer Implementation Date: Through June 1, 2024

Categories

Student Financial Aid Subrecipient Monitoring Equipment & Real Property Management Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 366599 2023-001
    Significant Deficiency
  • 366600 2023-001
    Significant Deficiency
  • 366601 2023-001
    Significant Deficiency
  • 366602 2023-001
    Significant Deficiency
  • 366603 2023-001
    Significant Deficiency
  • 366604 2023-001
    Significant Deficiency
  • 943040 2023-001
    Significant Deficiency
  • 943041 2023-001
    Significant Deficiency
  • 943042 2023-001
    Significant Deficiency
  • 943043 2023-001
    Significant Deficiency
  • 943044 2023-001
    Significant Deficiency
  • 943045 2023-001
    Significant Deficiency
  • 943046 2023-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
84.268 Federal Direct Student Loans $15.47M
84.063 Federal Pell Grant Program $1.46M
93.364 Nursing Student Loans $635,250
93.191 Graduate Psychology Education Program and Patient Navigator and Chronic Disease Prevention Program $323,639
93.925 Scholarships for Health Professions Students From Disadvantaged Backgrounds $262,800
93.732 Mental and Behavioral Health Education and Training Grants $232,171
84.038 Federal Perkins Loan Program $224,695
84.007 Federal Supplemental Educational Opportunity Grants $219,150
84.033 Federal Work-Study Program $121,686
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $77,188
84.425 Education Stabilization Fund $37,150
93.658 Foster Care_title IV-E $29,850
93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (sed) $2,152