Corrective Action Plans

FINDING 2024-002 Finding Subject: Child Nutrition Cluster - Eligibility Contact Persons Responsible for Corrective Action: Lacey Sturgeon, Food Service Director & Melissa Bell, Assistant Food Service Director Contact Phone Number and Email Addresses: (765) 893-4445 / lsturgeon@msdwarco.k12.in.us & mbell@msdwarco.k12.in.us Views of Responsible Officials: Option 1: We concur with the findings Description of Corrective Action Plan: Stronger internal controls are needed in regards to verification of Direct Certifications. We plan to make sure once the certifications are entered that the Food Service Director will check the work of the Assistant Food Service Director and show her approval by signing and dating each final report. Anticipated Completion Date: Effective Immediately

ReGenesis Health Care Corrective Action Plan Audit period: July 1, 2023 - June 30, 2024 Audit Finding: Incorrect Application of Sliding Fee Scale and Lack of Proper Documentation ________________________________________ Summary of Audit Finding – Federal Award Program Audit Department of Health and Human Services 2024-001 Health Centers Cluster – Assistance Listing No. 93.224 In a sample of 25 patient accounts, the audit revealed: • Four instances where the incorrect sliding fee scale was applied and lack of proper documentation maintained for sliding fee applications. ________________________________________ Corrective Actions: Staff Training Action: • Conduct mandatory training for General Practice Managers (GPMs) and Patient Service Representatives (PSRs), as well as for all newly hired front desk staff at orientation and annually thereafter. Content: • Process for sliding fee discount program eligibility determination. • Proper application of the sliding fee scale. • Documentation standards and quality improvement/assurance measures. Timeline: Begin training within 30 days from 1/21/25 and establish ongoing annual sessions. Responsible Party: Senior GPM, VP Strategy & Development Action Plan for Slide Application Process: PSR Responsibilities: • Continue scanning all completed slide applications into the system on the same day they are completed. • Ensure all relevant information is entered into the patient’s chart. • Assign scanned slide applications to respective GPMs for review in eCW. GPM Responsibilities: • Review slide applications in D jellybean daily for accuracy. The review should ensure that: o The document has been scanned into the chart. o Calculations are correct. o The correct proof of income and supporting documentation are included. • Discuss any slides requiring correction with the PSR and provide continued education as needed. • Address excessive errors through performance improvement plans and disciplinary actions if necessary. • GPM to ensure sliding fee schedule is correct and all documentation is present before marking the documents as approved in eCW. Auditing: • GPMs will run daily reports in eCW to audit the front desk’s slide application process. • Physicians Services Billing Manager or designee to review slide application information to ensure correct sliding scale has been applied. • Director of Quality Improvement will also audit process to ensure GPMs are completing this expectation. Standardized Procedures Action: • Review and update the Sliding Fee Discount Program Policy and Procedures annually and as needed • Implement a checklist for staff to ensure proper documentation. • The Physician Services Billing Manager will train billing staff on applying sliding fee discount program adjustments and will conduct internal audits to ensure the accuracy of payer status. Timeline: Review current policies and procedures by 2/7/25. Responsible Party: Senior GPM, Chief Financial Officer and Chief Administrative Officer Quality Control Measures Action: • Establish a quality control process to regularly review sliding fee documentation and application accuracy. Frequency: Quarterly reviews of a minimum of 10 patient accounts processed, from multiple ReGenesis Health Care sites where services from all scopes are rendered. Review Team: Compliance and Quality Improvement/Assurance teams Timeline: Begin reviews in Q1 2025. Responsible Party: Chief Administrative Officer, Chief Financial Officer, Director of Quality Improvement and Risk Management ________________________________________ Monitoring and Evaluation • Quarterly Reports: Summary of quality control findings shared with leadership. • Key Performance Indicators (KPIs): o Reduction in errors in sliding fee application. o 100% compliance with documentation requirements. • Audit Follow-Up: Prepare for Operational Site Visit (OSV) to confirm implementation of corrective actions. • Responsible Party: Chief Administrative Officer, Chief Financial Officer ________________________________________ Communication Plan • Staff Updates: Regular updates during Leadership and QI/QA team meetings on progress and reminders of proper procedures. • Leadership Reports: Quarterly updates to the Board of Directors and RHC Executive Team. ________________________________________ Conclusion ReGenesis Health Care is committed to addressing the identified issues and ensuring compliance with all sliding fee scale policies and guidelines. By implementing the outlined corrective actions, RHC aims to strengthen processes and maintain the highest standards of service for our patients. If the Department of Health and Human Services has questions regarding this plan, please call Rich Long, CFO, at 564-504-3658.

Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted management was unable to provide support for three of the 60 applications selected for testing. Additionally, for one of the 60 selections, the student was improperly classified as reduced when the annual income per the student’s application exceeded the corresponding threshold for that determination. Corrective Action Plan: The School Corporation will implement internal control procedures to ensure the applications are filed and maintained in a secure manner. The School Corporation will also implement internal control procedures to ensure that applications are formally reviewed by the Food Services Director and the Treasurer, so that applicants are accurately denied or approved for free or reduced meals. Person responsible for implementation and projected implementation date: The Corporation’s Food Services Director and Treasurer will be responsible for implementing the corrective action, which will be implemented immediately.

AL# and Program Expenditures: 84.063 ($679,498) Award Number: P063P233976 Federal Award Year: July 1, 2023 to June 30, 2024 Questioned Costs: $591.50 Condition Found: The amount of Pell grant awarded was calculated incorrectly for one of the twenty-one students who received Pell in our sample. The student in question was subjected to the lifetime eligibility used limitation. The College calculated the percentage of the Pell grant funds the student was eligible to receive correctly, but the percentage was applied to the full-time Pell award when the student was only enrolled ¾ time. Corrective Action Plan: The School returned $591.50 of Pell grant funds on February 4, 2025. Communication will be improved between the financial aid office and the register. Anticipated Completion Date: The corrective action was completed on February 4, 2025. Contact Person Valorie Quesenberry, Financial Aid Coordinator 513-763-6659

March 18, 2025

US Department of Health and Human Services

HIV CARE Formula Grants

Passed-through State of Hawaii Department of Health

1250 Punchbowl Street

Honolulu, HI 96813

Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2024 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745 Fort Street, Suite 2100, Honolulu HI 96813

Significant Deficiency

Finding No. 2024-001

Activities Allowed or Unallowed / Allowable Costs / Cost Principles

U.S. Department of Health and Human Services

Federal Assistance Listing Number 93.917

Condition

During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted two instances where HHHRC determined that the clients were ineligible; however, certain costs associated with these clients were charged to the RWB program. Specifically, we found that:

·         For one of the 60 clients selected, the client exceeded income threshold to be considered low-income, as defined by the state.

·         For one of the 60 client files selected, no intake documents were collected.

Criteria

Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements. To be eligible, clients must have a medical diagnosis of HIV/AIDS and be (a) a low-income individual, (b) a resident of the state, and (c) uninsured or underinsured, as defined by the state. Eligibility determination is required before participation in the RWB program during the in-take process. Re-assessments are performed at least once every 6 months thereafter.

Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. HIV status must be documented by a written statement from a medical provider. Lab results may only be used on an interim basis. Residency must be documented with a State ID card or a driver’s license, lease agreement, utility bill, official government mail, bank statement, pay stub, or a verification letter from an agency providing the client with housing. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client attesting to no income or very low income. For the payer of last resort criteria, HHHRC’s policy states that they must, at a minimum, assess and re-assess the client’s eligibility for benefits such as MedQuest. In addition, HHHRC must make reasonable efforts to secure funding, besides the Ryan White program, including pursuing enrollment into health care coverage.

Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.

Cause