Corrective Action Plans

Finding 1163543 (2025-001)

Material Weakness 2025

San Francisco Medical Center Outpatient Improvement Programs, Inc.

CA

Special Tests & Provisions Eligibility

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

View Audit 373229

Finding 1163540 (2025-002)

Material Weakness 2025

Independent School District No. 31

MN

Internal Control / Segregation of Duties Questioned Costs Eligibility

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.

View Audit 373219

Finding 1163529 (2025-001)

Material Weakness 2025

Faith Baptist Bible College and Theological Seminary

IA

Questioned Costs Eligibility Significant Deficiency

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

Finding 1163460 (2025-002)

Material Weakness 2025

North Colonie Central School District

NY

Procurement, Suspension & Debarment School Nutrition Programs Subrecipient Monitoring § 200.214

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.

View Audit 373046

Finding 1163430 (2025-002)

Material Weakness 2025

Coxsackie-Athens Central School District

NY

Procurement, Suspension & Debarment School Nutrition Programs Subrecipient Monitoring § 200.214

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.

View Audit 372996

Finding 1162972 (2025-001)

Material Weakness 2025

Sterling Health Solutions, Inc.

KY

Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking

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.

View Audit 372572

Finding 1162611 (2025-002)

Material Weakness 2025

Arlington Baptist University

CO

Student Financial Aid Questioned Costs Eligibility

Return of Title IV (R2T4) Calculations Planned Corrective Action: OFA will implement a process where an additional person will review R2T4 student records to ensure proper return of funds and calculations. OFA and VPAA will develop a process for instructors and Registrar to identify students that di...

Return of Title IV (R2T4) Calculations Planned Corrective Action: OFA will implement a process where an additional person will review R2T4 student records to ensure proper return of funds and calculations. OFA and VPAA will develop a process for instructors and Registrar to identify students that did not begin attendance. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Penny Hayes, Vice President of Academic Affairs Anticipated Date of Completion: Spring 2026

View Audit 372291

Finding 1162609 (2025-001)

Material Weakness 2025

Arlington Baptist University

CO

Student Financial Aid Reporting Eligibility

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Financial aid will be working closely with the Registrar and the Vice President of Academic Affairs to clean up all current records and CIP codes. The OFA and VPAA will maintain a schedule for upda...

Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Financial aid will be working closely with the Registrar and the Vice President of Academic Affairs to clean up all current records and CIP codes. The OFA and VPAA will maintain a schedule for updates of student statuses and CIP codes. The OFA will also use a secondary person to view reports before transmission. OFA will work with NCH to update CIP codes. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Penny Hayes, Vice President of Academic Affairs Anticipated Date of Completion: Fall 2026

View Audit 372291

Finding 1162541 (2025-001)

Material Weakness 2025

Neosho County Community College

KS

Questioned Costs Special Tests & Provisions Student Financial Aid § 200.303 § 200.62

CONDITION: During uring testing of 40 Pell Grant recipients, two awards were miscalculated--one over-award and one under-award--due to data-entry error and lack of secondary review. Corrective Action: The College has reviewed all Pell awards for the 2024-2025 award year to identify and correct any a...

CONDITION: During uring testing of 40 Pell Grant recipients, two awards were miscalculated--one over-award and one under-award--due to data-entry error and lack of secondary review. Corrective Action: The College has reviewed all Pell awards for the 2024-2025 award year to identify and correct any additional errors. Effective immediately, the Financial Aid Office will: 1. Implement a secondary review of all Pell award calculations prior to disbursement. 2. Reconcile ISIR data to the financial-aid system each term. 3. Provide annual staff training on Pell payment schedules and data accuracy. Documentation of the secondary review will be retained in each student's electronic record.

View Audit 372245

Finding 1162225 (2025-001)

Material Weakness 2025

Jacksonville Towers, INC

FL

HUD Housing Programs Eligibility Reporting

Oversight Agency for Audit, Jacksonville Towers, Inc., respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audi...

Oversight Agency for Audit, Jacksonville Towers, Inc., respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: April 1, 2024 through March 31, 2025 The finding from the March 31, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Section 8 Project Based Rental Assistance, ALN 14.195 Recommendation: The Project should implement procedures to ensure that initial and ongoing tenant eligibility documentation is obtained timely and properly maintained. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips Irene Phillips CFO

View Audit 372036

Finding 1161915 (2025-003)

Material Weakness 2025

Housing Authority of the City of Bradenton

FL

Questioned Costs Eligibility HUD Housing Programs

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Dominique J. Dunn, In...

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Dominique J. Dunn, Interim Executive Director, will be responsible to implement this corrective action by March 31, 2026.

View Audit 371807 Questioned Costs: $1

Finding 1161733 (2025-003)

Material Weakness 2025

Citadel Gardens, Inc. Dba the Woodlands at Citadel

MO

Allowable Costs / Cost Principles HUD Housing Programs Questioned Costs

Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Act...

Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Action We will keep all required documentation in tenant files and establish processes and procedures to ensure compliance with the provisions in HUD Handbook 4350.3, HUD Handbook 4381.5, and the Regulatory Agreement. Anticipated Completion Date December 31, 2025

View Audit 371688

Finding 1161678 (2025-004)

Material Weakness 2025

Village of Farwell

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.214

2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were per...

2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Village verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Village retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Village will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Ross Wilson, Village Clerk/Treasurer. Anticipated Completion Date: February 2026.

View Audit 371608

Finding 1161419 (2025-001)

Material Weakness 2025

William James College, Inc. & Affiliates

MA

Student Financial Aid Questioned Costs Special Tests & Provisions

Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; May 31, 2025 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the ins...

Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; May 31, 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 685.309(b)) Condition Of the nine students selected for enrollment reporting testing, two students within the sample were reported to NSLDS outside the maximum 60-day window. This was not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The College concurs with the finding. The College will continue to remain vigilant in its oversight over timely communication of enrollment reporting detail to NSLDS. In both instances, the data we had sent to the National Student Clearinghouse (NSC) was not received by NSLDS in a timely fashion. We will review our reporting schedule and make the appropriate changes to our reporting timeline to ensure the data we report to the NSC is subsequently received by NSLDS within regulations. Names of Contact Person Responsible for Corrective Action: Anna Lyons, Associate Registrar Anticipated Completion Date: September 1, 2025

View Audit 371288

Finding 1161133 (2025-001)

Material Weakness 2025

Boys & Girls Club of Weber-Davis

UT

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management

BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by th...

BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by the grant facilitator to provide member income data. However, to ensure compliance with federal reporting requirements, we will begin requesting income information from our members. In addition, we will reach out to our partner schools to determine whether they can confirm which of our members participate in the free or reduced lunch program.

View Audit 371150

Finding 1161116 (2025-003)

Material Weakness 2025

High Street Homes Inc.

MD

Eligibility HUD Housing Programs

Recommendation: The Project should perform a review of all tenant files to ensure all tenant files are complete with required documentation. Planned Corrective Actions: High Street Homes, Inc. acknowledges the deficiency related to tenant eligibility documentation. Management recognizes the importan...

Recommendation: The Project should perform a review of all tenant files to ensure all tenant files are complete with required documentation. Planned Corrective Actions: High Street Homes, Inc. acknowledges the deficiency related to tenant eligibility documentation. Management recognizes the importance of maintaining complete tenant files to ensure compliance with HUD requirements. Corrective actions taken include: • Immediate review of all current tenant files to confirm lease agreements and all required HUD forms are properly executed and on file. • Establishment of a tenant file checklist to ensure all required documentation is obtained and reviewed prior to tenant move-in. • Implementation of supervisory review of tenant files to verify completeness before occupancy is finalized. • Staff training on HUD eligibility and documentation requirements to reinforce compliance. High Street Homes, Inc. is committed to ensuring full compliance with HUD tenant eligibility documentation requirements.

View Audit 371113

Finding 1160966 (2025-001)

Material Weakness 2025

North Greenville University

SC

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Need Analysis Planned Corrective Action: 1. A revised internal procedure has been implemented, requiring a secondary review of all loan award allocations prior to disbursement to confirm compliance with federal regulations. 2. Staff members responsible for loan origination and packaging have been as...

Need Analysis Planned Corrective Action: 1. A revised internal procedure has been implemented, requiring a secondary review of all loan award allocations prior to disbursement to confirm compliance with federal regulations. 2. Staff members responsible for loan origination and packaging have been assigned refresher training on federal loan awarding requirements, with specific emphasis on annual and aggregate loan limits and the prioritization of subsidized eligibility. 3. System-level reports have been created to identify potential discrepancies in loan allocation, which will be reviewed monthly by the Financial Aid Office. Ongoing Monitoring: The Director of Financial Aid will oversee the monitoring process each term to ensure compliance with 34 CFR 685.203, and 34 CFR 685.301 requirements. Any discrepancies identified will be corrected immediately and documented as part of the institution’s internal compliance log. North Greenville University believes these corrective measures address the issue identified and will prevent recurrence of similar errors. Person Responsible for Corrective Action Plan: Cindi Patterson, Director of Financial Aid Anticipated Date of Completion: October 1, 2025

View Audit 371000

Finding 1160957 (2025-001)

Material Weakness 2025

Anderson University and Subsidiary

SC

Questioned Costs Eligibility Matching / Level of Effort / Earmarking

Need Analysis Corrective Action Plan: The Office of Financial Aid & Scholarships (OFAS) will do the following: • Correct the procedures for data entry in Workday. • Revise internal procedures to review loan awards prior to disbursement. • Explore/implement system checks in Workday to flag potential ...

Need Analysis Corrective Action Plan: The Office of Financial Aid & Scholarships (OFAS) will do the following: • Correct the procedures for data entry in Workday. • Revise internal procedures to review loan awards prior to disbursement. • Explore/implement system checks in Workday to flag potential over-awards. • Conduct random reviews of aid packages to ensure compliance. • Document system changes and over-award resolution. Person Responsible for Corrective Action Plan: Mike Sapienza, Senior VP for Enrollment Services Anticipated Date of Completion: May 31, 2026

View Audit 370986 Questioned Costs: $1

Finding 1160899 (2025-004)

Material Weakness 2025

Low Rent Housing Agency of Grinnell, Iowa

IA

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2025-004: Internal Control Structure Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2024-02 I agree with this finding. Continued steps will be taken to ensure no errors are made with extra effort and detail. – No esti...

Finding 2025-004: Internal Control Structure Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2024-02 I agree with this finding. Continued steps will be taken to ensure no errors are made with extra effort and detail. – No estimated date of completion

View Audit 370968

Finding 1160855 (2025-003)

Material Weakness 2025

Texas Christian University

TX

Questioned Costs Student Financial Aid Eligibility

The University has found a critical breakdown in communication between the Ranch Management department and the Registrar’s Office, stemming from informal, ad hoc processes that have not scaled with institutional needs. Specifically, there is no formal mechanism to ensure that updates to student stat...

The University has found a critical breakdown in communication between the Ranch Management department and the Registrar’s Office, stemming from informal, ad hoc processes that have not scaled with institutional needs. Specifically, there is no formal mechanism to ensure that updates to student statuses for the ranch management program are consistently reported or verified. To prevent recurrence of this issue, a process is being implemented that all Non-Degree programs will now be required to perform formal degree audits within the student information system. This ensures consistency in processing and aligns with practices currently used for degree-seeking students. Targeted training and communication will be provided to all Non-Degree program administrators to ensure clarity on new expectations, tools, and timelines. The Registrar’s Office will conduct periodic audits of non-degree program records to verify compliance and identify any further process improvements.

View Audit 370942 Questioned Costs: $1

Finding 1160658 (2025-002)

Material Weakness 2025

Sen Citizens Hsg Dev Fund CORP of Steuben County Two,inc

FL

HUD Housing Programs Reporting Eligibility

FINDING NO. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should implement procedures to ensure that all initial and ongoing tenant eligibility documentation is obtained timely and maintained in tenant files as required by HUD. Action Taken: Staff tr...

FINDING NO. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should implement procedures to ensure that all initial and ongoing tenant eligibility documentation is obtained timely and maintained in tenant files as required by HUD. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO

View Audit 370923

Finding 1160423 (2025-001)

Material Weakness 2025

Abilene Christian University

TX

Questioned Costs Student Financial Aid Eligibility

Single AUdit Report for 2024-2025 Reference/Finding Number 2025-001 Management's Planned Corrective Action Management acknowledges and understands the finding associated with Eligibility. The student's Pell award has already been corrected and accepted by COD. Management is working with IT to automa...

Single AUdit Report for 2024-2025 Reference/Finding Number 2025-001 Management's Planned Corrective Action Management acknowledges and understands the finding associated with Eligibility. The student's Pell award has already been corrected and accepted by COD. Management is working with IT to automate the enrollment change report to be sent on a weekly basis to validate that all increases in hours have been appropriately updated and processed. This will also become part of our required annual reconciliation process of the Pell grant program. Responsible Official Bridget Moore Director of Student Financial Services Abilene Christian University Estimated Completion Date July 24, 2025

View Audit 370836 Questioned Costs: $1

Finding 1160270 (2025-001)

Material Weakness 2025

The Episcopal Theological Seminary of the Southwest

TX

Student Financial Aid Eligibility Questioned Costs

Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education...

Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education Assistance Group to provide a comprehensive business process review of its financial aid operations. The objective of this review is to improve upon the functionality of processes, internal controls, and systems to ensure regulatory compliance and the effectiveness of service deliverables to students receiving financial aid. This review will include updates to policies, procedures, and internal controls for the import and export of electronic records, document tracking and file review, packaging and awarding, satisfactory academic progress, disbursement and reconciliation, withdrawal and Return to Title IV. Workflow and gap analysis will be performed to ensure intraoffice Title IV program compliance and best practices. Second, the institution has entered into a professional services agreement with Higher Education Assistance Group to provide interim staffing and third-party federal student aid processing including, but not limited to, counseling students and families on financial aid options, assisting with the management of Federal Direct Loan and Federal Graduate PLUS Loan programs to include student eligibility, file review, awarding, and origination and disbursement authorization using Populi, COD and other Department of Education software. In addition, Higher Education Assistance Group will provide additional Title IV training for personnel involved in federal student aid processing. With more than 35 years of experience, Higher Education Assistance Group and its team of seasoned consultants, all of whom have worked in federal student aid administration, whether in public/private colleges and universities or for the Department of Education itself, specializes in the compliant administration of Title IV student financial aid programs. The institution will adopt a supplemental internal control to cross-check student eligibility for Direct PLUS loans to ensure that an over-award is not originated and disbursed. Anticipated completion date: November 15, 2025

View Audit 370654 Questioned Costs: $1

Finding 1160151 (2025-001)

Material Weakness 2025

Burkesville Manor, Inc.

KY

Eligibility HUD Housing Programs

Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility req...

Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility requirements.

View Audit 370535

Finding 1159684 (2025-001)

Material Weakness 2025

Virginia Garcia Medical Health Center

OR

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration...

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration:  Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy.  Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation:  All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application.  Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS).  The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year.  Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls:  Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors.  Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025

View Audit 370272

Corrective Action Plans

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