Corrective Action Plans

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3.       The CEO reviews and signs off on each Draw Down Request prior to submission.
3.       The CEO reviews and signs off on each Draw Down Request prior to submission.
4.       Completed Draw Down Request Workbooks are submitted to HRSA for prior approval and retained for audit purposes.
4.       Completed Draw Down Request Workbooks are submitted to HRSA for prior approval and retained for audit purposes.
5.       Internal drawdown audits are conducted monthly to confirm alignment with federal cash management standards.
5.       Internal drawdown audits are conducted monthly to confirm alignment with federal cash management standards.
Corrective Action Plan:
Corrective Action Plan:
1.       Updated drawdown procedures have been incorporated into SCMRC’s financial policies and will be re-reviewed annually.
1.       Updated drawdown procedures have been incorporated into SCMRC’s financial policies and will be re-reviewed annually.
2.       Refresher training on 2 CFR § 200.305 and internal drawdown requirements will be conducted by Q4 2025.
2.       Refresher training on 2 CFR § 200.305 and internal drawdown requirements will be conducted by Q4 2025.
3.       Results of monthly drawdown audits will be included in the Finance Committee compliance dashboard starting in September 2025.
3.       Results of monthly drawdown audits will be included in the Finance Committee compliance dashboard starting in September 2025.
4.       SCMRC will continue to require documented CEO approval on all federal drawdown submissions to ensure sustained internal control.
4.       SCMRC will continue to require documented CEO approval on all federal drawdown submissions to ensure sustained internal control.
Corrective Actions Taken:
Corrective Actions Taken:
1. Implemented a 15-month rolling cash flow forecast in Q4 2024, updated weekly by the CEO and Controller in partnership with the contract accountant.
1. Implemented a 15-month rolling cash flow forecast in Q4 2024, updated weekly by the CEO and Controller in partnership with the contract accountant.
2. Finance staff monitor cash balances and disbursements at least twice per week to anticipate timing issues and support grant drawdown coordination.
2. Finance staff monitor cash balances and disbursements at least twice per week to anticipate timing issues and support grant drawdown coordination.
3. Established internal minimum balance thresholds and enabled low balance alerts to prevent overdrafts.
3. Established internal minimum balance thresholds and enabled low balance alerts to prevent overdrafts.
4. Consolidated underutilized accounts in 2025 and formalized contingency planning with SCMRC’s banking institution.
4. Consolidated underutilized accounts in 2025 and formalized contingency planning with SCMRC’s banking institution.
5. Conducted nonprofit cash flow management training for the CEO, Controller, and Board in Q2 FY25.
5. Conducted nonprofit cash flow management training for the CEO, Controller, and Board in Q2 FY25.
6. Included cash flow forecasting and liquidity discussions in monthly Finance Committee updates.
6. Included cash flow forecasting and liquidity discussions in monthly Finance Committee updates.
7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.
7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.
Corrective Action Plan:
Corrective Action Plan:
1. Continue weekly updates of the 12-month rolling cash flow forecast.
1. Continue weekly updates of the 12-month rolling cash flow forecast.
2. Maintain twice-weekly internal cash reviews to align disbursements with available cash and grant timing.
2. Maintain twice-weekly internal cash reviews to align disbursements with available cash and grant timing.
3. Monitor operating accounts against internal minimum thresholds and refine automated alerts as needed.
3. Monitor operating accounts against internal minimum thresholds and refine automated alerts as needed.
4. Reassess account structure annually and maintain contingency agreements with the bank.
4. Reassess account structure annually and maintain contingency agreements with the bank.
5. Require refresher training in cash flow management for new financial staff and Finance Committee members at least once annually.
5. Require refresher training in cash flow management for new financial staff and Finance Committee members at least once annually.
6. Maintain Finance Committee oversight of liquidity metrics, with trends tracked in monthly dashboards.
6. Maintain Finance Committee oversight of liquidity metrics, with trends tracked in monthly dashboards.
7. Review internal controls annually to ensure continued alignment with 45 CFR § 75.302(b)(4) and evolving HRSA guidance.
7. Review internal controls annually to ensure continued alignment with 45 CFR § 75.302(b)(4) and evolving HRSA guidance.
1. Enhance Document Retention Procedures: *We will update our document retention policy to clearly define retention periods for payroll-related records, ensuring compliance with legal and regulatory requirements. This will include retaining all necessary documentation such as payroll reports, tax fi...
1. Enhance Document Retention Procedures: *We will update our document retention policy to clearly define retention periods for payroll-related records, ensuring compliance with legal and regulatory requirements. This will include retaining all necessary documentation such as payroll reports, tax filings, and third-party payroll contracts. *A secure, organized system will be implemented for storing payroll-related documents, whether physical or digital. This will include utilizing secure cloud storage or an enterprise document management system with restricted access controls. *We will conduct a quarterly review to ensure that documents are being retained for the appropriate time frame and securely disposed of when no longer required. 2. Implement Stronger Controls During Payroll Provider Transitions: *We will formalize and document the process for changing third-party payroll providers. This process will include detailed steps for due diligence, transition planning, data transfer procedures, and ensuring continuous payroll processing during the transition period. *A project team will be assigned for every payroll provider change to ensure proper planning, including backup and contingency plans, data verification, and communication with both internal and external stakeholders. *A comprehensive review of the transition will be conducted after each change, including a reconciliation of payroll records to ensure that all data is accurately transferred, and all systems are functioning properly. 3. Vendor Oversight and Service Level Agreements (SLAs): *We will ensure that future contracts with third-party payroll providers include clear Service Level Agreements (SLAs) outlining the provider's responsibilities in terms of document retention, data security, and transition procedures. This will ensure that providers maintain the necessary standards and practices for managing payroll-related documents.
View Audit 364481 Questioned Costs: $1
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