Corrective Action Plans

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Finding 1165232 (2025-002)
Material Weakness 2025
2025-002: Eligibility Determination Not in Place or Consistently Applied Across all Programs Issue: Eligibility documentation for TANF-funded services was incomplete, inconsistently applied, or missing required verification of residency, citizenship, income, resources, or other eligibility factors. ...
2025-002: Eligibility Determination Not in Place or Consistently Applied Across all Programs Issue: Eligibility documentation for TANF-funded services was incomplete, inconsistently applied, or missing required verification of residency, citizenship, income, resources, or other eligibility factors. Documentation was not always collected, reviewed, or signed before services were provided, and eligibility determinations were not supported by a uniform process. Corrective Actions: Porter-Leath will implement a standardized eligibility checklist that incorporates all TANF eligibility requirements, including verification of residency, identity, citizenship, household composition, income, resources, and work participation when applicable. 1. Staff must complete the checklist and compile all supporting documents before any TANF-funded benefits are provided. 2. When allowed under governing regulations, the Organization will also accept and retain documented eligibility determinations from other qualified programs, including SNAP, TANF acceptance letters or other qualifying documentation to determine eligibility, as part of the verification packet. 3. Each eligibility packet will require supervisory review and signature confirming that all required elements are present, accurate, and complete prior to approving eligibility. 4. The final approved packet will be maintained in accordance with DHS documentation and retention requirements. Responsible Personnel: Program Managers, Family Services Staff, Supervisors Timeline: Checklist finalized within 10 days; training within 30 days; full training and implementation immediately thereafter. Monitoring: Quarterly file reviews will confirm that eligibility checklists are correctly completed, include required documentation or accepted verification from other programs when applicable, and contain supervisory approval.
Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend that management assign a designated individual to ensure rent reasonableness, income verification, and recertifications are completed accurately and on time, in accordance with HUD guidelines and the Aut...
Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend that management assign a designated individual to ensure rent reasonableness, income verification, and recertifications are completed accurately and on time, in accordance with HUD guidelines and the Authority's administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Director of HCV Program Administration and Ass istant Director of HCV Program Administration will be in charge of reviewing all Rent Reasonableness. Name(s) of the contact person(s) responsible for corrective action: Teresa J. Gonzalez, and Darrell Mciver. Planned completion date for corrective action plan: Effective immediately.
2025-002 – Child Nutrition Cluster – Eligibility – The District is aware of the missing eligibility documents for the Child Nutrition program and will implement new procedures and a plan to reduce the missing documentation. Responsible Officials – Heidi Engel, Enrollment & Transportation Coordinator...
2025-002 – Child Nutrition Cluster – Eligibility – The District is aware of the missing eligibility documents for the Child Nutrition program and will implement new procedures and a plan to reduce the missing documentation. Responsible Officials – Heidi Engel, Enrollment & Transportation Coordinator, and Jessica Christensen, District Food Service Manager Anticipated Completion Date – The District will correct this in the subsequent fiscal year.
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Will need to meet with academic records and determine if Doctorate program Dissertation 1-hour course can be coded and reported as full time to NSLDS Person Responsible for Corrective Action Plan: ...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Will need to meet with academic records and determine if Doctorate program Dissertation 1-hour course can be coded and reported as full time to NSLDS Person Responsible for Corrective Action Plan: Academic Records / Regina Bolding Harned - Registrar / Allison Sullivan – Director of Financial Aid Anticipated Date of Completion: 12/5/25
RCAP Solutions and the Rental Assistance Division is committed to ensuring our administration of the Housing Choice Voucher program is timely and accurate. The department recently implemented a new voucher management software which maintains improved tracking and management tools. Additionally, the ...
RCAP Solutions and the Rental Assistance Division is committed to ensuring our administration of the Housing Choice Voucher program is timely and accurate. The department recently implemented a new voucher management software which maintains improved tracking and management tools. Additionally, the department management is looking forward to utilizing the new software for improved communication with participants and owners and to utilize the integrated participant portal to reduce the time it takes for documentation to be processed. In addition, the department management is committed to working with the team to answer questions, improve performance, and decrease the time it takes for program representatives to administer the program all while maintaining accuracy and customer service.
Below you will find our corrective action plan to address the one finding in our FY 2025 Federal Single Audit, which received an unmodified opinion from our auditor Audit Finding #: 2025-1 Eligibility Determination Grantor: Department of Health and Human Services Federal Program Name: Low Income Hom...
Below you will find our corrective action plan to address the one finding in our FY 2025 Federal Single Audit, which received an unmodified opinion from our auditor Audit Finding #: 2025-1 Eligibility Determination Grantor: Department of Health and Human Services Federal Program Name: Low Income Home Energy Assistance (LIHEAP) Federal Assistance Listing (CFDA#): 93.568 Description: During the audited year July 2024 – June 2025, Access paid benefits for one individual whose income was over the threshold of 60% of the CT state median income. The income was documented, but incorrectly calculated. Statement of Concurrence: Access management concurs with the audit finding: Corrective Action: Access has put in place written procedures as follows: ○Access will provide additional training support and resources to staff to ensure that all LIHEAPapplications are certified in an accurate manner. ○Access will expand its internal file audit process to continue maintining a master log of all filesreviewed and also note any major findings so a timely response can be made.
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. This was an unusual circumstance where a student was withdrawn from the college before they were awarded any federal aid. The director has put in place procedure...
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. This was an unusual circumstance where a student was withdrawn from the college before they were awarded any federal aid. The director has put in place procedures to review the eligibility for federal aid of any student who withdraws to determine whether a post withdrawal disbursement is appropriate. Anticipated Completion Date: January 1, 2026
Date: October 16, 2025 To: Angela Baker, Finance Director From: Melissa Johnson, Early Education Director CC: Candy Scott, Executive Director Subject: NC Pre-K Audit • Purpose: To provide information on the requested review documentation for 40 child files for an NC Pre-K audit. • Details: While gat...
Date: October 16, 2025 To: Angela Baker, Finance Director From: Melissa Johnson, Early Education Director CC: Candy Scott, Executive Director Subject: NC Pre-K Audit • Purpose: To provide information on the requested review documentation for 40 child files for an NC Pre-K audit. • Details: While gathering requested information for an NC Pre-K audit, it was discovered that 11 of the 40 requested children’s files did not have review information in our online application portal, Survey Apply. The applications were processed following all guidelines and procedures, and supporting documentation is available. These documents include income spreadsheets, scorecards, and the date entered in the APP system. The review information, however, is not available in the online application database, and the reason for this has not been determined. Jennifer Williams, Office Manager, and I have both tried to recover this information without success. The requested files missing this information are Kever Pinto, Jackson Millsap, Brixton Beale, Zoey Matthews, Amir Salimov, Nolan McCowan, Rex Klein, Caleb Bernabe, Joseph Holland, Ocean Davis, and Bryson Bunch. • Outcome/Action Taken: Discovery of this possible glitch in the online application system has led us to put additional processes in place to ensure that this information is available upon request in the future. In addition to maintaining a saved copy of the income spreadsheet and scorecard on our internal server, we will now begin saving a copy of the review for each application that is processed. We are in the process of updating our NC Pre-K guidelines. This change will be reflected in these guidelines.
Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the in...
Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the institution, must be accurately reported within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. The changes include reductions or increases in attendance levels, withdrawals, graduations, and approved leaves of absence. It is the institution’s responsibility, as a participant in the Title IV aid programs, to monitor and report these changes to the National Student Loan Data System (“NSLDS”). (NSLDS Enrollment Reporting Guide November 2022 and 34 CFR 682.610) Condition Found Of the 16 students selected for enrollment reporting testing, seven students within the sample were reported to NSLDS outside the maximum 60-day window. This was not a statistically valid sample. Upon further inquiry, there were an additional 206 students included in the same batch reported to NSLDS that were not reported timely. Views of Responsible Officials and Planned Corrective Actions NELB is revising the use of the customized report to more accurately reflect student records and will leverage the student information system, Jenzabar, to produce enrollment reports. The Office of the Registrar, the Office of the Controller, and Office of Financial Aid will review the file for NELB graduates in the month of May and ensure 100% compliance with graduating reporting after submission. As part of the NELB year-end closing procedures, there will be an additional review in the month of June every year to ensure that the file of NELB graduates provided to the National Student Loan Data System is consistent and accurate. This year-end closing procedure will be initiated by the NELB Chief Financial Officer and will coordinate with the Office of Financial Aid, Office of the Registrar and the Controller’s Office. Names of Contact Persons Responsible for Corrective Action: Office of Financial Aid (Jenny Aquiar), Office of the Registrar (Max Brodsky) and the Controller’s Office (Sean Bendall). The NELB Chief Financial Officer (James White) will work collaboratively to ensure that the corrective action plan is completed by each of these three NELB departments by June 30, 2026. Anticipated Completion Date: June 30, 2026
Income Eligibility Audit Finding Response: Over-Income Eligibility Determination Finding: During the audit review, it was identified that the Authority erroneously assigned a unit to a potential tenant whose initial income exceeded the program's income eligibility threshold. Although the applicant's...
Income Eligibility Audit Finding Response: Over-Income Eligibility Determination Finding: During the audit review, it was identified that the Authority erroneously assigned a unit to a potential tenant whose initial income exceeded the program's income eligibility threshold. Although the applicant's income subsequently decreased prior to move-in, the Authority acknowledges that eligibility should have been confirmed and properly documented before final unit assignment. The tenant vacated the unit within six (6) months of occupancy. Authority Response: The Meridian Housing Authority (MHA) acknowledges the error in processing the applicant's income eligibility determination and recognizes that the assignment did not fully comply with HUD's established income verification and eligibility requirements. The Authority has reviewed the circumstances surrounding this incident and has determined that the error resulted from a timing and documentation oversight during the final verification phase. Corrective Action Taken: I. Immediate Case Review: The applicant's file was reviewed to verify all documentation and identify procedural gaps that led to the incorrect eligibility determination. 2. Staff Retraining: All occupancy and eligibility staff have been retrained on HUD income eligibility requirements, verification standards, and documentation retention procedures. 3. Revised Verification Protocol: The Authority has implemented an additional pre-move-in eligibility verification checkpoint to confirm applicant income status immediately prior to lease execution, and integration of a final income eligibility checklist into all applicant files. 4. Supervisory Review Requirement: A management-level review and approval is now required for all move-in certifications where an applicant's income falls near the program threshold. 5. Monitoring and Compliance Audit: Internal quality control reviews will be conducted quarterly to ensure continued compliance with HUD eligibility and verification standards. Anticipated Completion Date: Cunently in progress and will be completed by 3/31/2026 and ongomg. Contact Person: Ronald J. Turner, Sr. 2425 E Street, Meridian, MS 39301 601-693-4285
View Audit 374385 Questioned Costs: $1
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University enhance system controls to ensure disbursements match awards. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The Fin...
Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University enhance system controls to ensure disbursements match awards. View of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office normally attempts to disburse aid within the term for which it is designated. However, unusual workloads brought about by FAFSA disruptions, staffing reductions, and duty changes led to delays in the disbursement of some aid for the 2024-2025 school year. A significant amount of Fall 2024 and Spring 2025 aid was not disbursed until August and September 2025. While this does not fall outside of rules set by the Department of Education, later disbursements caused extra challenges for the Accounting Team and meant a delay in receiving federal funds into the organization. As of September 30, 2025, All Pell Grant and Federal Supplemental Education Opportunity Grant Funds for 2024-2025 were been dispersed — and the matching amounts have been certified by the Department of Education. All federal loans for 2024-2025 have been dispersed, with the exception of 11 students. Nine of the students still have not accepted or declined their loans. They have been given until October 15, or the loans will be rescinded. Two more students had errors that stopped disbursement. This issue is being resolved by the team within the next week. Actions taken to resolve the issue: The Financial Aid team is taking the following actions to ensure that financial aid is disbursed in the term it is awarded. (Note: there are always a few exceptions due to highly unusual circumstances.) • Restructuring the awarding process to disperse funds soon after Census Date, before manually checking each record for anomalies. In 2024-2025, the manual checking process was completed first, which dramatically delayed disbursement. • Restructuring duties to spread out the awarding processing among more than one team member to allow for it to be completed more quickly. • Reviewing and enhancing financial aid policies governing the awarding and disbursing process to ensure that the amounts match at the end of the fiscal year (May 31) for spring and fall terms, and at the end of the award year (August 1) for the summer term. Name(s) of the contact person(s) responsible for corrective action: Tricia Harris, Financial Aid Director Planned completion date for corrective action plan: The Financial Aid Office has already begun implementation of this action plan and will complete implementation before the end of the current school term.
View Audit 374299 Questioned Costs: $1
2025-001: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing, we noted four students out of forty did not have documentation in their f...
2025-001: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing, we noted four students out of forty did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be a instance of noncompliance with the Eligibility Compliance Requirement. This is a repeat finding, see Prior Year Audit Findings 2024-002. Corrective Action Plan LLCC has developed reports to identify students who require exit counseling. The Financial Aid Compliance Coordinator is responsible for overseeing and administering exit counseling process for students who are graduating, withdrawing, or dropping below half-time enrollment. Responsibilities include ensuring compliance with federal regulations, providing accurate loan repayment information, and maintaining proper documentation of completed counseling sessions. Responsible Person for Corrective Action Plan Alison Mills Implementation Date of Corrective Action Plan FY26
Corrective Action Plan (Management Response): The District acknowledges the finding and has initiated corrective measures:1. Policy Development: Draft comprehensive written policies and procedures addressing procurement, allowable costs, eligibility, reporting, and record retention for all major fed...
Corrective Action Plan (Management Response): The District acknowledges the finding and has initiated corrective measures:1. Policy Development: Draft comprehensive written policies and procedures addressing procurement, allowable costs, eligibility, reporting, and record retention for all major federal programs. 2. Approval and Adoption: Policies will be reviewed and formally adopted by the Board of Trustees prior to acceptance of further federal grants. 3. Training and Implementation: Staff responsible for federal program administration will be trained on the new procedures. Training materials will include checklists and step by step guides to ensure consistent application. 4. Monitoring: The District will conduct quarterly reviews of federal programs (if applicable) to ensure compliance. Exceptions will be documented and corrective action taken immediately.
Corrective Action MHA is now fully staffed with a current recertification reporting rate of over 96%. New staff members have been hired, trained and fully onboarded. An outside consultant was retained prior to staff hiring and processed all delinquent recertifications in the spring of 2025. Addition...
Corrective Action MHA is now fully staffed with a current recertification reporting rate of over 96%. New staff members have been hired, trained and fully onboarded. An outside consultant was retained prior to staff hiring and processed all delinquent recertifications in the spring of 2025. Additional staff training is being scheduled. Increased quality control procedures are being designed and implemented in coordination with a consultant to ensure ongoing activities meet Authority standards as well as Federal requirements.
View Audit 374083 Questioned Costs: $1
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the audi...
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the auditor to correct it.
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the audi...
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the auditor to correct it.
Finding 2025-002 - Accounting Controls - capital Fund Grant Management (Cash Management)-ALN 14.872 Public Housing capital Fund - Noncompliance and Significant Deficiency Corrective Action Plan: AHC has assigned two Senior Managers with eloccs secure system) access. Person Responsible: Shlrley Hende...
Finding 2025-002 - Accounting Controls - capital Fund Grant Management (Cash Management)-ALN 14.872 Public Housing capital Fund - Noncompliance and Significant Deficiency Corrective Action Plan: AHC has assigned two Senior Managers with eloccs secure system) access. Person Responsible: Shlrley Henderson, Deputy Director, Arnesha Nuniss and Abe Singh, Ex. Dir. Who is waiting for his eloccs access Anticipated Completion Date: September 10, 2025.
Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and ac...
Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g...
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Recommendation – We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual. Views of Responsible Officials and Planned Corrective Actions – CCI is implementing a system update within eCW to ensure the sliding fee schedule is accurately configured and consistently applied across all service locations. As part of this corrective action, CCI is developing a formal training program to ensure that all applicable employees understand the sliding fee requirements and possess the necessary knowledge to follow the established procedures. CCI is also establishing an internal review process to monitor compliance with the sliding fee policy. This process will include periodic sampling and review of sliding fee scale assessments to verify that eligibility determinations and discounts are being applied correctly and in accordance with policy. Any identified discrepancies will be addressed through targeted staff retraining or process adjustments, as appropriate. These corrective actions are designed to strengthen internal controls, ensure consistent application of the sliding fee program, and maintain compliance with regulatory and organizational requirements. Reason for Recurrence – CCI experienced significant turnover within the Revenue Cycle Department during fiscal year 2025, which contributed to delays in updating system configurations and conducting required reviews. Anticipated Completion/Implementation Date: End of Fiscal Year 2026
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discou...
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discount Program (SFDP) policies, procedures, and forms for better clarity and tracking. - Continue to perform monthly internal audits of sliding fee transactions and document audit findings, corrective actions, and report results to leadership. - Retrain current staff quarterly based on the monthly internal audit results. - Train all new staff at new hire orientations. - Validate staff understanding through annual knowledge checks and competency assessments. - Integrate SFDP compliance into staff performance evaluations. - Maintain centralized log of all SFDP applications and determinations. Proposed Completion Date: December 31, 2025
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring C...
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Food and Nutrition Service Coordinator. 4. Planned Completion Date for CAP The CAP was implemented immediately during audit fieldwork performed in October 2025. 5. Plan to Monitor Completion of CAP The Food and Nutrition Service Coordinator will continually review applications and supporting documentation for completion and eligibility accuracy. Any issues noted will be communicated to appropriate staff and fixed immediately.
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
View Audit 373203 Questioned Costs: $1
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not...
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not to be eligibility list will be reported to the Food Service Director and Purchasing Agent. This list will be updated and checked annually.
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual ...
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual basis. Anticipated implementation date is October 1, 2025 by responsible person(s) District Business Official and District Treasurer Kelsey Reed.
Sterling Health Solutions (SHS) acknowledges the errors identified and is committed to addressing the underlining reasons that caused them. SHS will review all applicable policies and provide additional training to ensure that all personnel responsible for and involved in the sliding fee discount pr...
Sterling Health Solutions (SHS) acknowledges the errors identified and is committed to addressing the underlining reasons that caused them. SHS will review all applicable policies and provide additional training to ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. SHS will monitor Slide applications on a daily basis and complete, at a minimum, quarterly audits of each clinic’s Slide applications. SHS will provide ongoing training, as necessary, to address any concerns identified during the daily monitoring or quarterly audits.
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