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Finding Number: 2024-032 Audit Type: Single Audit Finding Title: Delayed Final Reimbursement Due to Unresolved Agency Requests Related Finding: 2024-023 (Yellow Book) 1. Contact Person Responsible for Corrective Action Name: Shannah Weaver Title: City Clerk Department: Finance Department 2. Planned ...
Finding Number: 2024-032 Audit Type: Single Audit Finding Title: Delayed Final Reimbursement Due to Unresolved Agency Requests Related Finding: 2024-023 (Yellow Book) 1. Contact Person Responsible for Corrective Action Name: Shannah Weaver Title: City Clerk Department: Finance Department 2. Planned Corrective Action The City will designate a grants coordinator to monitor agency requests and ensure timely responses. 3. Anticipated Completion Date September 30, 2026 4. Management's Response Management concurs and will improve communication with funding agencies. 5. Status of Prior Year Finding This is a newt finding.
Finding 5: Cost of Attendance (COA) Budget Documentation Condition: Cost of Attendance Budgets to determine students unmet need were not provided by the College. (34 CFR 685.102(b)) • New SOP requiring documentation (e.g., printout, electronic file) of the student's specific COA be included in their...
Finding 5: Cost of Attendance (COA) Budget Documentation Condition: Cost of Attendance Budgets to determine students unmet need were not provided by the College. (34 CFR 685.102(b)) • New SOP requiring documentation (e.g., printout, electronic file) of the student's specific COA be included in their financial aid file. • A full reconstruction of COA budgets is underway using historical tuition and fee schedules, room and board, and survey data. • Documentation has been compiled and saved for all student budget categories and dependency statuses. • Formal COA Development Process: o COA budgets are now reviewed and approved annually by the Financial Aid Director in collaboration with the Finance Office. o Data sources include tuition/fees, room and board, bookstore pricing, transportation estimates, and student expense surveys. • Component Breakdown: o COA budgets are broken down by: § Enrollment status (full-time, part-time) § Housing status (on-campus, off-campus, with parent) • Staff Training: o Financial Aid staff trained annually on COA development and documentation requirements. • Expected date of completion: 06/2026 Finding 6: Federal Programs Expenditure Submission Condition: The Office of Financial Aid submitted unreconciled expenditures within the Fiscal Operations Report and Application to Participate (FISAP) for Federal Pell Grant, Federal SEOG and Federal Work-Study. • New SOP requiring a formal monthly reconciliation of all Federal Pell, SEOG, and FWS program expenditures between the Financial Aid ledger and the Business Office/General Ledger. • Development of a detailed FISAP preparation checklist, requiring final reconciliation sign-off by both the DFA and the Business Manager prior to submission. • Cross-training for new FA and Business Office staff on the specific accounting and reporting requirements for all Title IV program funds reported on the FISAP • Submitted an amended FISAP to correct discrepancies and reflect accurate expenditures. • Conducted a line-by-line reconciliation of all federal fund expenditures for Pell, SEOG, and FWS for the reported year. • Implemented a dual-approval process for FISAP data involving both Financial Aid and Finance teams. • Monthly Reconciliation Protocol: o Financial Aid Office and Business Office will jointly reconcile Title IV disbursements, drawdowns, and expenditures on a monthly basis. o Reconciliations will be documented and archived for audit purposes. • Training and Accountability: o Annual training on FISAP completion and reconciliation best practices for all involved staff. o One staff member from each office designated as the FISAP lead and held accountable for data accuracy. • Expected date of completion: 06/2026 Finding 7: Reconciliation of Title IV program Condition: The College did not reconcile all Title IV programs between the office of Financial Aid and the Business Office, including Federal Pell Grant, Federal SEOG, Federal Work- Study, and Federal Direct Loans. (34 CFR 685.309(b)(5)) • Conducted a full reconciliation for all Title IV programs for the 2024–2025 award year to identify and resolve discrepancies. • Verified drawdowns in G5 against actual disbursements and adjusted ledger entries where necessary. • Establish Monthly Reconciliation Process: o A formal monthly reconciliation schedule is now in place for Pell, SEOG, FWS, and Direct Loans. o Both offices jointly reconcile: § Disbursements from SIS § G5 drawdowns § COD (Common Origination and Disbursement) data § General ledger entries • Clear Division of Responsibilities: o Financial Aid Office: Responsible for accurate awarding, disbursing, and reporting to COD. o Business Office: Responsible for drawdowns, cash management, and posting to the general ledger. o Both sign off monthly on reconciliation reports. • Training and Internal Controls: o Cross-training provided to both teams on Title IV reconciliation best practices and compliance standards. o Developed and implemented internal procedures for handling discrepancies • Expected date of completion: 06/2026
Inadequate Approval Controls Over Adjusting Journal Entries and Invoices Recommendation: We recommend following documented controls to enforce approval for adjusting journal entries. We also recommend ensuring invoice processing workflows include mandatory approvals before payment. We further recomm...
Inadequate Approval Controls Over Adjusting Journal Entries and Invoices Recommendation: We recommend following documented controls to enforce approval for adjusting journal entries. We also recommend ensuring invoice processing workflows include mandatory approvals before payment. We further recommend conducting periodic audits to verify compliance with approval policies. Action Taken: CMJTS migrated to a new accounting software in February of 2025. This software has systematic approval workflows built in to ensure approvals are done on journal entries before they are posted and invoices before they can be paid.
View Audit 374211 Questioned Costs: $1
Finding: 2024-004: Significant Deficiency in Internal Controls over Compliance – Eligibility Name of Contact Person: Tray Miller Controller Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: Management will ensure eligibility forms are thoroughly reviewed. Proposed C...
Finding: 2024-004: Significant Deficiency in Internal Controls over Compliance – Eligibility Name of Contact Person: Tray Miller Controller Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: Management will ensure eligibility forms are thoroughly reviewed. Proposed Completion Date: 6/30/25
2024-002: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and for both the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Form HUD-50059, Owner’s Certification of Compliance with HUD’s Tena...
2024-002: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and for both the required documentation to determine eligibility, as required by the HUD regulations, could not be located as follows: • Form HUD-50059, Owner’s Certification of Compliance with HUD’s Tenant Eligibility and Rent Procedures was not updated before the tenant’s anniversary date. • There was no verification of income by a third party provided. • There was no signed move-in/move-out inspection form provided. • There was no signed lease provided. Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.
View Audit 374026 Questioned Costs: $1
MATERIAL WEAKNESS 2024-002: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the following findings were noted: • Form HUD-50059, Owner’s Certification of Compliance with HUD’s Tenant Eligibility and Rent Procedures was not updated for the year tested • Move-in...
MATERIAL WEAKNESS 2024-002: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing and the following findings were noted: • Form HUD-50059, Owner’s Certification of Compliance with HUD’s Tenant Eligibility and Rent Procedures was not updated for the year tested • Move-in/move-out inspection form was not provided • Lease was not provided • Annual recertification of income by a third party was not provided Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.
View Audit 374024 Questioned Costs: $1
2024-002: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and signatures, as required by HUD regulations, were missing from Form HUD-50059, Owner’s Certification of Compliance. Additionally, our testing indicated that the required deposits to the replacement res...
2024-002: Section 202, Assistance Listing No. 14.157 Two tenant files were selected for testing and signatures, as required by HUD regulations, were missing from Form HUD-50059, Owner’s Certification of Compliance. Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.
2024-002: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing, and none of the required documentation to determine eligibility, as required by the HUD regulations, was provided. Additionally, our testing indicated that the required deposits to the replacement reserve ...
2024-002: Section 202, Assistance Listing No. 14.157 One tenant file was selected for testing, and none of the required documentation to determine eligibility, as required by the HUD regulations, was provided. Additionally, our testing indicated that the required deposits to the replacement reserve account had not been made for the last quarter of the Corporation’s fiscal year for any tenants. Recommendation: We recommend the Corporation establish procedures and internal controls to ensure that all required documentation is maintained, and all required reserve deposits are made timely, in accordance with HUD requirements. Action Taken: Management concurs with this recommendation. Since assuming property management on June 1, 2025, ULREDC has conducted a tenant file audit. All property management staff have been properly trained to ensure compliance with certification, documentation, and inspection requirements. Missing documentation, including Form HUD-50059, income verifications, and leasing inspections, is being corrected. Replacement reserve deposits were delayed because properties were not cash flowing. As leasing stabilizes, deposits will resume and be verified once RealPage is fully active. RealPage will serve as the compliance and record-retention platform. Quarterly internal compliance reviews will be instituted to confirm file accuracy and documentation completeness.
View Audit 374016 Questioned Costs: $1
Finding No. 2024-006 Housing Trust Fund Program Federal Assistance Listing Number #14.275 Statement of Condition In connection with our lease file review, we noted two instances of four tenants tested where management did not provide support that they performed a 3rd party income verification in acc...
Finding No. 2024-006 Housing Trust Fund Program Federal Assistance Listing Number #14.275 Statement of Condition In connection with our lease file review, we noted two instances of four tenants tested where management did not provide support that they performed a 3rd party income verification in accordance with policy. Corrective Action Plan As a result of the 2024 audit, a new process is set up to ensure that new employees receive HUD annual training. Management will continue to ensure that 3rd party income verification is performed in accordance with policy.
Finding No. 2024-005 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner was unable to provide a listing that detailed the available to HOME tenants the contracted number and type of HOME units and therefore we were unable to test the H...
Finding No. 2024-005 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner was unable to provide a listing that detailed the available to HOME tenants the contracted number and type of HOME units and therefore we were unable to test the HOME program compliance for the audit year. Corrective Action Plan REACH utilizes a 3rd party property management company to manage the two properties located in Washougal, Washington. Management is setting up a new process to ensure that the 3rd party property management company can provide all required information.
Finding No. 2024-004 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. This is considered a temporary noncompliance as follows: "Next Available Unit"...
Finding No. 2024-004 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. This is considered a temporary noncompliance as follows: "Next Available Unit" rule: The owner must rent the next comparable or smaller unit that becomes vacant to a low-income household. Temporary noncompliance: The unit is temporarily out of compliance with HOME requirements, but the property can regain compliance by following the "next available unit" rule. Unit conversion: If the owner fails to comply and rents a comparable vacant unit to a non-low-income tenant, the over-income unit loses its low-income status and the building's compliance is reduced. A two bedroom unit did become available in 2024 and this tenant was not relocated. Corrective Action Plan A new review process is in placed to review the HOME units that will be re-classified the next time there is a vacant unit of the corresponding size/type.
Finding No. 2024-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action Plan A new process is in placed to review HOME unit count wh...
Finding No. 2024-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action Plan A new process is in placed to review HOME unit count when a unit becomes available.
Finding No. 2024-002 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition In connection with our lease file review, we noted six instances of eight tenants tested where management did not provide support that they performed a 3rd party income veri...
Finding No. 2024-002 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Statement of Condition In connection with our lease file review, we noted six instances of eight tenants tested where management did not provide support that they performed a 3rd party income verification in accordance with policy. Corrective Action Plan As a result of the 2024 audit, a new process is set up to ensure that new employees receive HUD annual training. Management will continue to ensure that 3rd party income verification is performed in accordance with policy.
Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide Section VIII, Subsection E. Documentation Required states: Grantees must use adequate financial management s...
Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide Section VIII, Subsection E. Documentation Required states: Grantees must use adequate financial management systems that follow generally accepted accounting principles (GAAP) and provide adequate fiscal control and account records including cost accounting records supported by documentation. Grantees must also maintain all back up documentation and invoices to support the costs paid with SSVF funds.” Condition: During the OBO review, OBO found the Organization was unable to provide a general ledger detail that separated administrative costs from general costs. Cause: Because the Organization’s SSVF administrative costs are allocated payroll expenses, management was unaware they needed to segregate the administrative costs in the general ledger. Effect: The Organization’s failure to provide a general ledger that separates administrative and general expenses increases the risk of inaccurate financial results being provided at closeout or unauthorized and ineligible expenses being charged to the award, which may result in subsequent funding shortages for other qualified expenses. Questioned Costs: None Identification as a repeat finding: This is a repeat finding. Corrective Action: As of 2/17/2025 OKVU added sub-coding to the general ledger to identify administrative labor costs under 7000 – Salaries & wages, 7100 – Fringe benefits and 7200 – Payroll taxes bases on direct allocations provided to the payroll system. This information will be provided by report from the payroll system and added via journal entry to the GL.
Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section V, Subsection C. Determining Income Eligibility, provides a summary of asset inclusions...
Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section V, Subsection C. Determining Income Eligibility, provides a summary of asset inclusions and exclusions for use in evaluating assets. Assets must be evaluated at entry to SSVF and at recertification. Condition: The Office of Business Oversight (OBO) performed a review to assess the Organization’s compliance with SSVF program and other federal requirements and regulations. During this review, OBO found 45 case files missing evidence that the grantee evaluated assets (inclusions and exclusions) for certification of eligibility. Cause: Management misinterpreted the guidance and was not aware of the need to document asset evaluations if the veteran did not have any assets. Effect: The Organization’s failure to obtain and keep the adequate income supporting documentation in the case file may result in the Organization providing services to an ineligible veteran or household. Questioned Costs: None Identification as a repeat finding: This is a repeat finding. Corrective Action: As of 12/06/2024 OKVU implemented the addition of the Asset Calculation Worksheet to the veteran case file. To ensure compliance the requirement was also added to the discharge file QC checklist and the SSVF policy and procedure manual updated. As of 12/11/2024 all case manager staff were provided training.
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the education stabilization grant for 2026, as well as into future periods.
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the education stabilization grant for 2026, as well as into future periods.
View Audit 372554 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2026.
Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2026.
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the Title I grant for 2026, as well as into future periods.
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the Title I grant for 2026, as well as into future periods.
View Audit 372554 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the special education grant for 2026, as well as into future periods.
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the special education grant for 2026, as well as into future periods.
View Audit 372554 Questioned Costs: $1
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Edward Ritter, Commissioner of Finance Phone: (914) 654-2000 (2) Audit Finding 2024-002 - The City did not follow controls for eligibi...
Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Edward Ritter, Commissioner of Finance Phone: (914) 654-2000 (2) Audit Finding 2024-002 - The City did not follow controls for eligibility certifications of individuals enrolled in the HIPP-RAP. (a) Implementation Plan of Actions - Management has initiated a full review and recertification of all participants in the HIPP-RAP to determine if any additional participants were missing eligibility determinations. (b) Implementation Date - This will be implemented and completed for the year ended December 31, 2025. (c) Persons Responsible for Implementation - The Commissioner of Development and the City Council.
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
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. Leonard Spicer, Execu...
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. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175 Questioned Costs: $1
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.
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