Corrective Action Plans

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Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with federal eligibility requirements. Name, address, and telephone of District contact person: Heather Korten, Director of Business Services 2689 Hoover Ave SE Port Orchard, WA 9836...
Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with federal eligibility requirements. Name, address, and telephone of District contact person: Heather Korten, Director of Business Services 2689 Hoover Ave SE Port Orchard, WA 98366 (360) 874-7015 Corrective action the auditee plans to take in response to the finding: 1. Documented Eligibility Review The District will require a documented eligibility review for each student included on any future CWSD application. This review will verify that each student is both: A dependent of active-duty military personnel; and A student with a qualifying severe disability under CWSD program requirements. 2. Comparison to Impact Aid Source Data Prior to submission, the Business Department will compare the students included on the CWSD application to the District’s source documentation for military-connected students, including data maintained through the U.S. Department of Education Impact Aid process. 3. Secondary Review by Business Services The Business Department will perform an independent secondary review of the CWSD application before submission. The application will not be submitted until Business Services has reviewed and documented agreement between the application data and the District’s supporting eligibility records. 4. Special Services Review of Disability Eligibility and Costs The Special Services Department will remain responsible for identifying students with disabilities who may meet the CWSD criteria and for supporting the special education cost information included in the application. 5. Written Procedures and Sign-Off Requirements The District will establish written procedures identifying the staff responsible for preparing, reviewing, approving, and retaining documentation for the CWSD application. The procedures will require documented review and approval by both Special Services and Business Services prior to submission. 6. Documentation Retention The District will retain supporting documentation for each student included on the application, including military-connected status, disability eligibility support, cost documentation, review checklists, and final application approval. 7. Training and Annual Review Staff involved in preparing or reviewing the CWSD application will review applicable program requirements annually before the application is prepared. Anticipated date to complete the corrective action: June 30, 2026
The BGCNEO accounting team and government grants team will develop and maintain a shared drive to securely store all required eligibility forms and supporting documentation. Prior to submitting grant billings, BGCNEO accounting staff will review the shared drive to ensure all billed participants hav...
The BGCNEO accounting team and government grants team will develop and maintain a shared drive to securely store all required eligibility forms and supporting documentation. Prior to submitting grant billings, BGCNEO accounting staff will review the shared drive to ensure all billed participants have the appropriate documentation on file and have received approved eligibility determination from the funder.
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return fede...
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return federal reimbursements for unallowable expenditures claimed under Medicaid and SNAP. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. DSS staff is in the development phase of implementing new automated procedures to ensure timely and accurate action is taken to discontinue benefits of deceased clients when date of death information is received and matched to the Connecticut Department of Public Health’s State Vital Records Office. Action has been taken to correct the errors cited, including discontinuing the benefits of the individuals that were verified as deceased, and recouping the overpayments as appropriate. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department identified cases where overrides that were applied during the public health emergency were not removed. This resulted in individuals remaining enrolled inappropriately. Our Business Systems Division is implementing a tiered resolution approach, beginning with individuals enrolled in the Medicare Savings Program and HUSKY-C coverage. Please note: The Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational ...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational Protocol. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees in part with this finding. Condition #1: DSS agrees that participation end dates were not updated timely due to cross-system manual entry limitations. Reconciliation procedures and supervisory oversight will be strengthened. Condition #2: DSS agrees that participation suspensions were not consistently reflected across systems due to timing delays. Monitoring and real-time reconciliation controls will be enhanced. Condition #3: DSS agrees approved costs exceeded institutional thresholds in limited cases. Variances were clinically justified, reviewed, and authorized. DSS will strengthen documentation and internal protocols to ensure clearer policy alignment. Condition #4: DSS agrees that the documentation was incomplete in one instance. Internal review standards will be reinforced to ensure comparative cost analyses are consistently documented. Please note, the Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under Centers for Medicare and Medicaid Services’ (CMS) Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Christine Weston, Program Division Director (860) 424-5012
Recommendation: The Department of Social Services should strengthen internal controls to ensure that each Children’s Health Insurance Program recipient is eligible for the program according to the state plan and federal regulations. Corrective Action Plan as Reported by the Department of Social Serv...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that each Children’s Health Insurance Program recipient is eligible for the program according to the state plan and federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. Condition #1: This was a processing error and was independently addressed. Condition #2: The findings were for cases that were granted prior to the implementation of the Department’s manual review process, which includes updating third-party information in the Health Insurance Exchange (HIX) system after verifying policy information. This process was officially started in May 2025. It is a post-enrollment function since it is permissible for clients to self-attest to having third-party liability (TPL) at the time of application. We expect to see a reduction in this type of error in future audits. There is an inevitable delay in DSS being notified of any discrepancies with TPL details due to the timing of that information being updated from carriers and then provided to DSS. With our new process, we can close these cases as soon as that information is available to us. Condition #3: There are multiple root causes related to this finding, including Premium Payment Module file transaction issues, reversing system functionality that was temporarily implemented during the COVID-19 Public Health Emergency which resulted in lingering enrollment issues, and staff processing errors. DSS regularly reviews age-out cases to take the necessary actions to close. Please note, the Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under Centers for Medicare and Medicaid Services’ (CMS) Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should strengthen internal controls over sanctions to ensure compliance with Temporary Assistance for Needy Families child support enforcement requirements. Corrective Action Plan as Reported by the Department of Social Services: The Department agree...
Recommendation: The Department of Social Services should strengthen internal controls over sanctions to ensure compliance with Temporary Assistance for Needy Families child support enforcement requirements. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with the finding. DSS Economic Security and Office of Child Support Services implemented a new child support non-cooperation referral process on November 25, 2025. It is task based, assures an accurate and complete universe of sanction notices for child support non-cooperation are provided, and assures staff process and document all required sanctions. Anticipated Completion Date: November 25, 2025 Department of Social Services Contact Person: Tricia Morelli, Program Administrative Manager (860) 424-5519
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive temporary family assistance in accordance with federal laws and the Temporary Assistance for Needy Families State Plan. Corrective Action Plan as Reported by the Depa...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive temporary family assistance in accordance with federal laws and the Temporary Assistance for Needy Families State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The error occurred due to a system issue that did not trigger the discontinuance of benefits for a household that had received 60 months of time-limited benefits. The Department will take action to correct the system functionality to ensure incorrect payments are not made to households that have received 60 months of time-limited benefits. An overpayment has been created, and the recovery of the error amount is in process. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient and current documentation to support the reasonableness of rent for the Continuum of Care Program. Corrective Action Plan as Reported by the Department o...
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient and current documentation to support the reasonableness of rent for the Continuum of Care Program. Corrective Action Plan as Reported by the Department of Mental Health and Addiction Services: DMHAS Housing and Homeless Services Unit verbally instructed providers that they must complete, prior to client move-in, accurately, sign and retain documentation regarding the comparable units when completing the Rent Reasonableness on December 17, 2024. On December 24, 2024 and December 19, 2025, these instructions were sent to the providers via email. On February 4, 2025, DMHAS updated the CoC Operations Guide with the full instructions for completing the Rent Reasonableness and the retention of supporting documentation. DMHAS will continue to randomly review a sample of Rent Reasonable documents throughout the year and will provide training and technical assistance to providers on the completion and retention of Rent Reasonableness documentation. Anticipated Completion Date: June 30, 2026 Department of Mental Health and Addiction Services Contact Person: Alice Minervino, Director, Housing and Homeless Services Alice.minervino@ct.gov (860) 418-6942
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient documentation to support participant eligibility and accurately calculate client income and rental assistance payments in the Continuum of Care Program. ...
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls to ensure providers maintain sufficient documentation to support participant eligibility and accurately calculate client income and rental assistance payments in the Continuum of Care Program. Corrective Action Plan as Reported by the Department of Mental Health and Addiction Services: In 2026, DMHAS will continue to conduct trainings on CoC Fiscal Requirements. As in the past, these trainings will be recorded and available for viewing on the Connecticut Balance of State Continuum of Care (CTBOS) website. DMHAS Housing and Homeless Services Unit staff conduct mandatory in-person and virtual Technical Assistance visits for the funded agencies to provide guidance and training on the United States Department of Housing and Urban Development (HUD) required eligibility regulations Income Calculation and Documentation. On November 1, 2023, DMHAS implemented a Microsoft Excel Workbook that is fully inclusive of the DMHAS required paperwork, including the income calculation, lease, contract, as well as initial and recertification which standardizes the documents for each participant. On December 19, 2025, the workbook was updated to enhance internal controls over the use of Rent Reasonableness forms and calculations of client income and rental assistance payments. The DMHAS Housing and Homeless Services Unit will continue to work with the DMHAS Fiscal Services Bureau to ensure payments are made accurately, correctly and on-time. Anticipated Completion Date: June 30, 2026 Department of Mental Health and Addiction Services Contact Person: Alice Minervino, Director, Housing and Homeless Services Alice.minervino@ct.gov (860) 418-6942
Recommendation: The Department of Social Services should strengthen internal controls to identify the agency responsible for each client’s eligibility determination and document benefit iteration approvals for the Summer Electronic Benefits Transfer Program for Children. Corrective Action Plan as Re...
Recommendation: The Department of Social Services should strengthen internal controls to identify the agency responsible for each client’s eligibility determination and document benefit iteration approvals for the Summer Electronic Benefits Transfer Program for Children. Corrective Action Plan as Reported by the Department of Social Services: The Department disagrees with this finding. Condition #1: Eligibility for the Summer EBT program is established through multiple pathways: receipt of Supplemental Nutrition Assistance Program (SNAP) benefits, Temporary Family Assistance (TFA), or HUSKY A coverage, and through applying for and receiving an eligibility determination for either the National School Lunch Program or the Summer EBT program itself. Determining eligibility is a shared responsibility between DSS and the State Department of Education (SDE), and children qualify through multiple pathways simultaneously. DSS maintains a record within its eligibility system and compiles reports of all eligible children. When eligibility is established through any additional means, the child’s record is then analyzed against all previous issuances to ensure duplicate participation and double issuance does not occur. Title 7 CFR Part 292.16 (a)(5)(i) requires the Summer EBT agency to establish a master issuance file which contains all information needed to identify eligible children, issue Summer EBT benefits, record the participation activity for each household and supply all information necessary to fulfill reporting requirements. The agency is not required to specify which program(s) were used to determine eligibility, which is reasonable given that there may be multiple overlapping avenues of eligibility. The implication that DSS is somehow not compliant or able to identify the source of eligibility is inaccurate. DSS can identify this information on an individual basis through reviewing the child’s receipt of SNAP, TFA, HUSKY A, or through its ongoing coordination and communication with SDE. Condition #2: It is not a requirement of the business systems division to request approval for each issuance. Each year the Department issues benefits for this program in a consistent manner. Since there were no changes to the process during the audit period, approval was not sought for the issuances. Business systems would only seek approval if there was a change to the process. Anticipated Completion Date: N/A Department of Social Services Contact Person: Dan Giacomi, Program Division Director 860-424-5080
The District reviewed the existing internal controls for compliance with federal eligibility requirements and have added additional management oversight of existing processes to improve completeness. In addition, the district will implement process improvements to increase transparency of record ret...
The District reviewed the existing internal controls for compliance with federal eligibility requirements and have added additional management oversight of existing processes to improve completeness. In addition, the district will implement process improvements to increase transparency of record retention.
Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be fo...
Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, the Corporation paid expenses in the amount of $305 on behalf of an affiliate from project cash without HUD approval. The amount due to the Project as of December 31, 2025 is $305. b. Action(s) Taken or Planned on the Finding This finding has been corrected and the affiliate reimbursed the property within the first quarter of 2026.
CAPHMLC is implementing corrective actions to ensure full compliance and strengthen internal controls. 1. CAPHMLC will reinforce its requirement that all LIHEAP participant files include complete hard-copy documentation supporting eligibility determinations. 2. A standardized documentation checklist...
CAPHMLC is implementing corrective actions to ensure full compliance and strengthen internal controls. 1. CAPHMLC will reinforce its requirement that all LIHEAP participant files include complete hard-copy documentation supporting eligibility determinations. 2. A standardized documentation checklist will be implemented and required in each file to verify completeness prior to approval. 3. A documented supervisory review will be required for all applications. Evidence of this review must include the reviewer's initials or signature and the date ofreview. 4. Applications will not be processed until the required review is completed and documented. CAPHMLC will provide mandatory trammg to all LIHEAP staff and supervisors on documentation requirements, record retention standards, and supervisory review procedures. Updated policies will be formally communicated, and staff will be required to acknowledge their unde-rstanding e fc-these-requirements. To ensure ongoing compliance, CAPHMLC will implement monthly quality assurance reviews of a sample of participant files to verify completeness of documentation and evidence of supervisory review. Results will be reported to management, and any identified deficiencies will be addressed promptly. Procedures will also be strengthened to ensure consistency between electronic records maintained in F ACSPro and hard-copy files. These corrective actions will be implemented within 90 days, with trammg and policy reinforcement completed within 30 days, and monitoring procedures initiated within 60 days. Supervisors will be responsible for enforcing compliance, and instances of noncompliance will be addressed in accordance with CAPHMLC personnel policies and procedures. Management will monitor the effectiveness of these corrective actions through ongoing quality assurance activities and periodic internal reviews to ensure sustained compliance with applicable requirements.
The supervisor of registration employees will oversee quarterly patient file reviews of patients registered as beneficiaries to ensure that the required documentation is acquired from the patients. Patient files that lack the required documentation, will be flagged in a way that will be noticeable b...
The supervisor of registration employees will oversee quarterly patient file reviews of patients registered as beneficiaries to ensure that the required documentation is acquired from the patients. Patient files that lack the required documentation, will be flagged in a way that will be noticeable by anyone that has access to the files. The clinic will also consider an outside department like PRC which also validates beneficiary information could get involved in a mid-fiscal year review of the beneficiary patient files to provide a secondary review of the files. The anticipated completion date will be 9/30/2026.
RE: Funding 2025-001 – Incorrect student status, Corrective Action Plan To whom it may concern: Student Financial Assistance Cluster (ALNs: 84.063 and 84.268) Management concurs with the findings. Management acknowledges that the condition identified is primarily attributable to staff turnover assoc...
RE: Funding 2025-001 – Incorrect student status, Corrective Action Plan To whom it may concern: Student Financial Assistance Cluster (ALNs: 84.063 and 84.268) Management concurs with the findings. Management acknowledges that the condition identified is primarily attributable to staff turnover associated with the closure of the school, which resulted in disruptions to established processes and reduced the effectiveness of controls over the determination and documentation of student eligibility. Management has ensured the appropriate reporting has now been made to the NSLDS. The SFA program has been terminated and therefore will not impact future audits. Leadership Responsible: Colleen Walsh Dean, Student and Alumni Services Lawrence Memorial/Regis College (781) 979-3000 Anticipated Completion date: May 30, 2026
Views of Responsible Officials: The Foundation will retroactively receive the FFATA reports for their sub-recipients, and going forward will ensure that the FFATA reports are received and submitted for all sub-recipients.
Views of Responsible Officials: The Foundation will retroactively receive the FFATA reports for their sub-recipients, and going forward will ensure that the FFATA reports are received and submitted for all sub-recipients.
Views of Responsible Officials: Each screening is uploaded with the first payment request to any vendor, supplier, or consultant. The Foundation will retroactively document the date the screening was conducted, the date the screening was reviewed, as well as the name of the person performing the rev...
Views of Responsible Officials: Each screening is uploaded with the first payment request to any vendor, supplier, or consultant. The Foundation will retroactively document the date the screening was conducted, the date the screening was reviewed, as well as the name of the person performing the review of the screening for all vendors, suppliers, or consultants that were paid during FY26. Going forward, the date the screening was performed, along with the person reviewing the screening and the date of that review, will be documented. The Foundation performs new screenings annually for all vendors, suppliers and consultants at the beginning of the fiscal year.
Management’s Response: Management understands the importance of ensuring information is reported accurately and timely and the requirement to report to the NSLDS the enrollment status of students who receive federal funds. The University will review its controls and procedures to ensure that not onl...
Management’s Response: Management understands the importance of ensuring information is reported accurately and timely and the requirement to report to the NSLDS the enrollment status of students who receive federal funds. The University will review its controls and procedures to ensure that not only are status changes reported to the Clearinghouse, but also that the enrollment changes are reported appropriately from the National Student Clearinghouse to NSLDS. Views of Responsible Officials and Corrective Action: We will reassess controls, review these processes and implement controls, including multiple layers of review, to ensure that timely and accurate enrollment reporting is made. Furthermore, the reporting data was appropriately updated subsequent to the required timeframe. Name of Responsible Person: LaShanda Chamberlain, Director of Student Financial Aid Implementation Date: Immediately
Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 60 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services...
Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 60 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 43 CUA Safety Assessments, (b) 38 CUA Safety Plans, (c) 15 CUA PA Model Risk Assessments, (d) 8 CUA Documented Client Visits (Structure Case Notes), (e) 21 FAST Family Advocacy Forms, (f) 21 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 15 School Aged Report Cards, (h) 23 CUA Authorization to Release Information, (i) 12 CUA Immunizations, (j) 22 DHS Court Order Sheets, (k) 11 Child’s Photo, (l) 9 Initial CUA Single Case Plan, (m) 11 6-Month Updates to CUA Single Case Plan, (n) 2 Initial CUA Case Service Conference Summary Report, and (o) 2 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 23 DHS Service Authorization Forms, (b) 25 DHS CUA Provider Referral Forms, and (c) 20 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Enhancement of the Quality Assurance Department to strengthen oversight, monitoring activities, and internal review processes across programmatic and administrative functions. 3. Implementation of monthly reviews of client files and supporting documentation to ensure accuracy, completeness, and compliance with contractual and funding requirements. 4. Provision of enhanced staff training focused on the review of audit findings, identification of control deficiencies, and timely implementation of corrective actions. Name of the contact person responsible for corrective action: Asif Mehmood, Chief Financial Officer asif.mehmood@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2026
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that all documentation supporting the sliding discount provided is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization identified challenges and errors in the prior eligibility workflow after the 2024 audit. Over the course of 2025, the Organization experienced turnover in management and front desk personnel in the dental department. The workflows were modified when the new eligibility manager joined the Organization. Upon hiring a new dental manager and patient access (front desk) manager, workflows and procedures were also modified to ensure the front desk reviews insurance coverage upon check in. The system is set up so the Organization does not need manually adjust all claims, so the claim was auto-posted for the visit identified above. Our corrective action plan is already established, although it was put into place after the date of service of the visit identified above. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Amanda Craig, CFO, at 970-710-5062.
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to untimely tenant recertifications and missing income documentation. Management reviewed the circumstances that contributed to the delayed comple...
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to untimely tenant recertifications and missing income documentation. Management reviewed the circumstances that contributed to the delayed completion of tenant recertifications and incomplete documentation and determined that existing internal monitoring procedures did not consistently ensure tenant recertifications were completed within required timeframes. To address these issues, management has implemented corrective actions designed to strengthen oversight and improve the timeliness and completeness of tenant recertifications. These actions include reinforcing internal tracking procedures for recertification due dates, enhancing supervisory review of tenant eligibility files, and providing additional training to staff responsible for tenant eligibility determinations and income verification. Management expects these corrective actions to be fully implemented and operating effectively for all tenant recertifications going forward, thereby improving compliance with federal award requirements and reducing the risk of future untimely tenant recertifications or missing documentation. Anticipated Completion Date The corrective action is in the process of being implemented and expected to be completed in fiscal year 2026.
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to the inability to locate certain tenant files. Management acknowledges that one of the eight tenant files selected for audit testing was not ava...
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to the inability to locate certain tenant files. Management acknowledges that one of the eight tenant files selected for audit testing was not available and concurs with the disclosure that nine of the forty tenant files for the program could not currently be located. Management has evaluated the circumstances contributing to the missing files and determined that existing record retention and file management procedures did not sufficiently ensure that all tenant documentation was safeguarded and readily retrievable. Management recognizes that the absence of tenant files limits the ability to demonstrate compliance with federal award requirements and to support costs charged to the program. To address this issue, management has initiated corrective actions to strengthen document retention and file management controls. These actions include implementing enhanced tracking and reconciliation processes for tenant files, improving secure storage and retention practices, and reinforcing staff responsibilities for maintaining complete and accessible tenant records. Management also plans to conduct periodic internal reviews to confirm that tenant files are properly maintained and available for monitoring and audit purposes. Specifically we plan to: 1. All physical resident files are stored in locked cabinets or secured file rooms with access limited to authorized personnel, including Property Managers, Assistant Property Managers, Compliance Specialists, and designated corporate staff. 2. Access to records will be restricted based on job function and necessity 3. There will be a formal file transfer and chain-of-custody process with required signatures 4. File transfers between properties will be by locked file transport boxes marked as confidential. 5. Employees will be required to maintain direct control of files during transport. 6. All files will be maintained during required retention periods. Management believes that these corrective actions will improve compliance with record retention requirements and reduce the risk of missing documentation in the future. Anticipated Completion Date The corrective action is in the process of being implemented and expected to be completed in fiscal year 2026.
Late Single Audit Submission Description of Finding Uniform Guidance 2 CFR 200.512(a) requires that each organization’s audit must be completed and the data collection form and reporting package should be submitted within the earlier of 30 days after receipt of the auditor’s report or nine months af...
Late Single Audit Submission Description of Finding Uniform Guidance 2 CFR 200.512(a) requires that each organization’s audit must be completed and the data collection form and reporting package should be submitted within the earlier of 30 days after receipt of the auditor’s report or nine months after the end of the audit period. The Single Audit packages for the City’s fiscal years 2022-2025, were not submitted timely to the Federal Audit Clearinghouse. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action Management will review existing processes and controls related to audit readiness and financial reporting to ensure that all required financial reports are submitted timely. The City will implement a formal audit and Single Audit submission calendar with defined internal deadlines, assign clear staff responsibilities for preparing and submitting required documents, and use a centralized tracker to monitor audit milestones and ensure timely submission to the Federal Audit Clearinghouse. Staff involved in federal reporting will also receive annual training on Single Audit requirements to ensure compliance with federal timelines going forward. Name of Contact Person Shannon McCue, City Budget Director Projected Completion Date June 30, 2026
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Cheney School District No. 360 September 1, 2024 through August 31, 2025 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regul...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Cheney School District No. 360 September 1, 2024 through August 31, 2025 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with federal Title I assessment system security and eligibility requirements.Name, address, and telephone of District contact person: Jamie Reed, Director of Finance and Operations 12414 S. Andrus Road (509) 559-4501 Corrective action the auditee plans to take in response to the finding: Assessment system security: Assessment Administration Procedures have been reviewed for the 2025-2026 school year by Building Assessment Coordinators (BAC). They will ensure a Test Security Building Plan (TSBP) will be provided for the WIDA assessment administered in their building this school year. BAC Assessment Google folders for 2026-2027 school year are currently being adjusted to provide additional organization to ensure all required documents are completed by BAC's then submitted to the District Assessment Coordinator (DAC) upon completion of the assessment window. Eligibility: The District has already begun corrective actions to address these concerns. District staff have reviewed federal Title I ranking and allocation requirements, including OSPI guidance related to poverty ranking methodology and the 75 percent rule. The District will implement additional review procedures during the annual Title I application and budgeting process to verify poverty calculations, school rankings, and allocation methodologies prior to submission. The District will also document comparability and supplemental funding determinations for any qualifying schools not directly served with Title I funds. Additionally, the District will provide targeted training for staff responsible for federal program administration and budgeting to ensure ongoing compliance with federal and OSPI Title I requirements. Anticipated date to complete the corrective action: Corrective review for the end of the 25-26 school year and full corrective action for the 26-27 school year.
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