Corrective Action Plans

Finding 1177928 (2024-001)

Material Weakness 2024

NY

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.512

The Organization has developed and implemented written procedures to ensure timely submission of the data collection form and reporting package to the FAC. These procedures: (1) assign primary responsibility for the FAC submission to the Director; (2) require preparation of the FAC submission checkl...

The Organization has developed and implemented written procedures to ensure timely submission of the data collection form and reporting package to the FAC. These procedures: (1) assign primary responsibility for the FAC submission to the Director; (2) require preparation of the FAC submission checklist immediately upon receipt of the draft auditor’s reports; and (3) incorporate the FAC deadline into the Organization’s annual compliance calendar. Training on the new procedures was provided to key finance staff.

View Audit 391291

Finding 1177916 (2024-003)

Material Weakness 2024

Special Olympics Michigan, Inc.

MI

Reporting Internal Control / Segregation of Duties § 200.512 § 200.520

2024-003 Finding - In accordance with 2 CFR § 200.512(a), the audit must be completed and the reporting package, which includes the Data Collection Form (SF-SAC), must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receipt of the auditor's report(s...

2024-003 Finding - In accordance with 2 CFR § 200.512(a), the audit must be completed and the reporting package, which includes the Data Collection Form (SF-SAC), must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Recommendation - The Organization should review internal controls and implement necessary procedures to ensure that accounting processes are completed timely so the audit can be completed within the parameters of the due date. Action to be taken – Additional staffing has been added and long with ensuring that bank reconciliations are completed by the 10th day after the month ends in order to ensure audit field work is completed in a timely manner. Responsible person – Tony Postma, Interim Chief Financial Officer

View Audit 391262

Finding 1177707 (2024-004)

Material Weakness 2024

Burke County Board of Education

GA

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.303 § 200.403

All journal entries related to the grant will be submitted by the Finance Director to the Director in charge of the grant for approval.

View Audit 391130

Finding 1177706 (2024-002)

Material Weakness 2024

Burke County Board of Education

GA

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.303 § 200.403 § 200.415

The School District will review established internal controls and procedures with pertinent staff to ensure all are being followed. Expenditures related to the grant will be reviewed by personnel in charge of the grant to ensure proper approvals are maintained.

View Audit 391130

Finding 1177694 (2024-001)

Material Weakness 2024

Talmud Torah Darkei Avos - Monsey

NY

Internal Control / Segregation of Duties Reporting School Nutrition Programs

Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 sched...

Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 schedule of findings and questioned costs is discussed below. Finding 2024-001: Federal Awards Program Audit U.S. Department of Agriculture Child Nutrition Cluster Programs Deficiency: See Finding 2024-001 Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 05/31/2026 Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has engaged the audit firm for their upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end August 31, 2025. Mr. Yaakov Rotenberg, food service director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-371-2476. Contact Person Responsible for Corrective Action: Yaakov Rotenberg, Food Service Director

View Audit 391115

Finding 1177682 (2024-015)

Material Weakness 2024

Southeast New Mexico College

NM

Student Financial Aid Reporting Significant Deficiency § 200.512

Recommendation The College should continue to work with the accounting department and accounting systems to assist its auditor to catch up its financial reporting and records to allow for the completion of future audits. Corrective Action Unfortunately, due to the untimely completion and release of ...

Recommendation The College should continue to work with the accounting department and accounting systems to assist its auditor to catch up its financial reporting and records to allow for the completion of future audits. Corrective Action Unfortunately, due to the untimely completion and release of the June 30, 2023 audit report (released on August 8, 2025 - over two years after the end of the June 30, 2023 fiscal year audit), the College did not have the opportunity to review and begin a timely process of addressing a majority of the audit findings until well after the end of the audit period. While the College is committed to corrective action, the delayed delivery of the June 30, 2023 audit limited the ability to implement corrective measures earlier. The College is working proactively to ensure that these issues are resolved going forward. It is important to note that Southeast New Mexico College was a newly established independent community college, having formally separated from New Mexico State University (NMSU) as of April 2022. During this transition period, many administrative processes, including federal grant compliance procedures, were in the process of being developed, transitioned, and implemented independently from NMSU systems. As a result, certain policies, procedures, and documentation processes were not yet fully established or operational at the time of the audit. To ensure timely future submissions, the following corrective actions have been implemented. Revised Timeline and Calendar Controls: • A compliance calendar has been developed and integrated into the Business Office workflow to monitor federal reporting deadlines, including the DCF due date. This calendar includes reminder notifications at 90, 60 and 30 days before the March deadline. Internal Review Process: • A designated compliance officer or fiscal services staff member has been assigned responsibility for tracking the DCF submission process and coordinating with the external auditors to ensure timely receipt of the final audit. Audit Planning Coordination: • Annual audit planning meetings now include a discussion of reporting deadlines, and the contract with the external audit firm will include a clause requiring delivery of the final audit in a timeframe that supports compliance with federal submission timelines. Training and Awareness: • Relevant staff will have completed training in Uniform Guidance reporting requirements, including DCF submission procedures and deadlines to ensure full understanding of the importance of timely compliance. Due of Completion: August 31, 2025 Responsible Party(ies) Vice President for Business and Finance (or appropriate official), Dean of Business and Finance, Director of Finance, Accounts Receivable Coordinator, Business Office Manager

View Audit 391086

Finding 1177663 (2024-003)

Material Weakness 2024

Lake County, Colorado

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

2024-003: Noncompliance and Material Weakness in Internal Controls Over the Reporting Requirement Federal Assistance Listing Number(s): 21.027, 21.032 Program Title: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) and Local Assistance and Tribal Consistency Fund Federal Award Year: 2022-20...

2024-003: Noncompliance and Material Weakness in Internal Controls Over the Reporting Requirement Federal Assistance Listing Number(s): 21.027, 21.032 Program Title: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) and Local Assistance and Tribal Consistency Fund Federal Award Year: 2022-2023 Name of Federal Agency: U.S. Department of Treasury Name of pass-through entity: Direct, Colorado Department of Local Affairs, and various COVID-19 Program: Yes Federal Program: Coronavirus State and Local Fiscal Recovery Funds and Local Assistance and Tribal Consistency Fund Problem: Several required quarterly and one annual grant reports were not submitted by the required deadlines, resulting in noncompliance with grant program requirements and indicating deficiencies in internal controls over reporting in accordance with 2 CFR 200.303. Actions Steps: Creation of a Lake County Grant Policy establishing standardized processes for the application, administration, tracking, and reporting of federally awarded funds to address internal control requirements under 2 CFR 200. This framework is also applied to all other grant funding sources (federal, state, and private) to ensure consistency and oversight. Status: New Lake County Financial Policies and Procedures, including grant application, management, tracking, and reporting requirements, were adopted in 2025. These policies strengthen internal controls, support ongoing compliance with 2 CFR 200, and provide continuous managerial oversight of awarded funds. Dates: January 2025 Goal: To accurately and reliably manage and report on all granted funds awarded to Lake County Government.

View Audit 391078

Finding 1177653 (2024-009)

Material Weakness 2024

Jackson County

OH

Internal Control / Segregation of Duties

The CDJFS has reviewed its internal RMS training and oversight processes to ensure full compliance with federal and state requirements. Moving forward, the RMS Coordinator will continue to closely monitor RMS observations and verify that all documentation and comment requirements are met by each emp...

The CDJFS has reviewed its internal RMS training and oversight processes to ensure full compliance with federal and state requirements. Moving forward, the RMS Coordinator will continue to closely monitor RMS observations and verify that all documentation and comment requirements are met by each employee. If an employee fails to uphold RMS requirements, the RMS Coordinator will immediately notify the employee’s direct supervisor and the Deputy Director of Fiscal so that additional training and guidance can be provided. Should issues persist after retraining, the matter will be elevated to the Assistant Director for evaluation and potential disciplinary action. The agency remains committed to reinforcing strong internal controls through ongoing training, supervisory oversight, and adherence to documentation standards. These measures will help ensure the accuracy and integrity of RMS reporting and prevent future occurrences.

View Audit 391060

Finding 1177643 (2024-007)

Material Weakness 2024

Jackson County

OH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Period of Performance § 200.403

The Sheriff’s Office has separated from the person who oversaw these grants. New procedures have been implemented, and the Chief Deputy is now involved in overseeing these grants as well.

View Audit 391060

Finding 1177638 (2024-006)

Material Weakness 2024

Jackson County

OH

Subrecipient Monitoring Period of Performance Reporting

The Municipal Court Probation Department took corrective action on March 6, 2025 by enacting a grant reporting policy applicable to all grants in which they administer. The Sheriff’s Office has separated from the person who oversaw these grants. New procedures have been implemented, and the Chief De...

The Municipal Court Probation Department took corrective action on March 6, 2025 by enacting a grant reporting policy applicable to all grants in which they administer. The Sheriff’s Office has separated from the person who oversaw these grants. New procedures have been implemented, and the Chief Deputy is now involved in overseeing these grants as well.

View Audit 391060

Finding 1177606 (2024-002)

Material Weakness 2024

South Seven Senior Village

WA

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that additional internal controls are required to ensure eligibility is verified, current, and fully documented prior to the provision of services. The instance identified resulted from a misinterp...

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that additional internal controls are required to ensure eligibility is verified, current, and fully documented prior to the provision of services. The instance identified resulted from a misinterpretation of system information and insufficient verification procedures to confirm current eligibility. In response, OlyCAP has initiated corrective actions to strengthen eligibility determination controls, including reinforcing documentation requirements prior to service initiation, clarifying staff procedures for reviewing eligibility system data, and providing additional training to ensure eligibility requirements are consistently understood and applied. Management is committed to maintaining compliance with federal program requirements and improving internal controls to prevent similar occurrences in the future. Estimated Completion Date: In progress / Ongoing Responsible Party: Program Management with Finance Oversight

View Audit 390989

Finding 1177605 (2024-001)

Material Weakness 2024

South Seven Senior Village

WA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that stronger internal controls over the single audit reporting process are necessary. During the audit period, the organization did not have sufficiently formalized procedures to ensure timely sub...

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that stronger internal controls over the single audit reporting process are necessary. During the audit period, the organization did not have sufficiently formalized procedures to ensure timely submission of the SF-SAC reporting package. Since identifying this issue, OlyCAP has begun implementing improved internal controls. During the first half of 2024, the department experienced the loss of all lead fiscal staff, which required subsequent corrections and adjustments to 2024 reporting once external consultants were engaged. This work occurred concurrently with the organization’s transition from antiquated systems to newer platforms. As part of the corrective actions, OlyCAP has established clearly defined responsibility for audit submissions, implemented internal deadlines that precede federal filing requirements, and strengthened management oversight to verify timely completion and submission. OlyCAP is committed to improving its internal control environment to ensure future single audit submissions are completed accurately and within required deadlines. Estimated Completion Date: Completed Responsible Party: Executive Director

View Audit 390989

Finding 1177024 (2024-001)

Material Weakness 2024

Buckeye Community School

OH

Internal Control / Segregation of Duties

The School will request that the management company provide audited financial statements, presenting combined or consolidating columns for each of its schools, or an agreed-upon procedures report, to meet the reporting requirements in future periods.

View Audit 390880

Finding 1177011 (2024-007)

Material Weakness 2024

City of Compton

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The new Grants policy will be reviewed and approved by the City Manager and implemented by June 2026. Community Development staff will ensure a succession plan is in plac...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The new Grants policy will be reviewed and approved by the City Manager and implemented by June 2026. Community Development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: June 2026 Responsible Person(s): City Manager

View Audit 390871

Finding 1177010 (2024-006)

Material Weakness 2024

City of Compton

CA

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The recommendations are included in the new Grants policy. The City Manager shall review and submit to City Council for approval and adoption. Expected implementation by ...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The recommendations are included in the new Grants policy. The City Manager shall review and submit to City Council for approval and adoption. Expected implementation by June 2026. Planned Implementation Date: June 2026 Responsible Person(s): City Manager

View Audit 390871

Finding 1177009 (2024-005)

Material Weakness 2024

City of Compton

CA

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation and has implemented hiring for temporary work assignments in order to facilitate update. Corrective Action Plan: The HR and payroll software will be updated by the City by December 2026. Planned ...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation and has implemented hiring for temporary work assignments in order to facilitate update. Corrective Action Plan: The HR and payroll software will be updated by the City by December 2026. Planned Implementation Date: December 2026 Responsible Person(s): City Manager

View Audit 390871

Finding 1177005 (2024-002)

Material Weakness 2024

Smithfield Housing Authority

RI

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.403

Smithfield Housing Authority invoices are now reviewed by the Executive Director prior to approval and payment. Supervisory review has been strengthened to ensure compliance with federal cost principles. In addition, monthly reviews of program expenditures for our regular board meetings, including t...

Smithfield Housing Authority invoices are now reviewed by the Executive Director prior to approval and payment. Supervisory review has been strengthened to ensure compliance with federal cost principles. In addition, monthly reviews of program expenditures for our regular board meetings, including the Housing Voucher Cluster, are already in place. This helps to verify accuracy and appropriate allocation of costs.

View Audit 390862

Finding 1176975 (2024-003)

Material Weakness 2024

City of Warr Acres, Oklahoma

OK

Reporting Internal Control / Segregation of Duties

Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending December 31, 2024. Additionally, the City did not submit its audit report to the FAC within nine months from year ending December 31, 2024. In conjunct...

Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending December 31, 2024. Additionally, the City did not submit its audit report to the FAC within nine months from year ending December 31, 2024. In conjunction with our fiscal year 2024 audit, please see the City’s corrective action plan below: To address the audit finding, management acknowledges the finding regarding the delayed submission of the City’s audit report to both the Oklahoma State Auditor and Inspector and the Federal Audit Clearinghouse (FAC). We agree that the combination of turnover in key financial reporting positions and the impact of a natural disaster contributed to delays in completing the fiscal year 2023 financial close and subsequent filings. The City recognizes the importance of timely reporting to maintain compliance with state and federal requirements. Management is committed to strengthening internal controls, improving communication among departments, and ensuring that future audit submissions are completed within the required deadlines. The City feels the delay in this audit was caused from waiting on the Bethany–Warr Acres Public Works Authority Trust Audit to be completed for the City’s audit to be completed. City received first draft letter April 2025.

View Audit 390804

Finding 1176896 (2024-001)

Material Weakness 2024

City of Jurupa Valley

CA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.329

The City will enhance internal controls to ensure FFATA reporting is prepared in accordance with program requirements. The City hired a new senior accountant assigned to ensure that required reports from various agencies are filed timely.

View Audit 390741

Finding 1176871 (2024-001)

Material Weakness 2024

Lifespan Corporation and Affiliates

RI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.403 § 200.430

Corrective Action Plan Year Ended September 30, 2024 Finding 2024-001 AL Numbers: 97.036 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Correction Action: We will identify and quantify the total amount of the labor cost overstatement. We will report our results to t...

Corrective Action Plan Year Ended September 30, 2024 Finding 2024-001 AL Numbers: 97.036 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Correction Action: We will identify and quantify the total amount of the labor cost overstatement. We will report our results to the granting agency and work with them to resolve the questioned costs by May 31, 2026. To prevent recurrence, management will revise our review control of project applications to reconcile the calculation file to invoice support to verify accuracy. Contacts: Stephen Almonte, VP of Finance and Corporate Controller Salmonte3@brownhealth.org Mark Adelman, Director Public Policy and Federal Advocacy Madelman@brownhealth.org Planned Completion Date: May 31, 2026

View Audit 390719

Finding 1176855 (2024-003)

Material Weakness 2024

City of Stamford

TX

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.328

In reference to audit finding 2024-003, wp.ich refers to submitting a project and expenditure report within the required timeframe. The city will train the city's finance department in how to file the project and expenditure report within the required timeframe by working with the city's third-party...

In reference to audit finding 2024-003, wp.ich refers to submitting a project and expenditure report within the required timeframe. The city will train the city's finance department in how to file the project and expenditure report within the required timeframe by working with the city's third-party financial consultant and the city manager.

View Audit 390700

Finding 1176853 (2024-001)

Material Weakness 2024

City of Stamford

TX

Reporting Internal Control / Segregation of Duties

In reference to the audit finding 2024-001, which refers to internal controls over financial reporting. The city is in the process of training city employees how to reconcile balance sheets on a quarterly basis . Bank reconciliation will be performed regularly; the city will utilize a third-part con...

In reference to the audit finding 2024-001, which refers to internal controls over financial reporting. The city is in the process of training city employees how to reconcile balance sheets on a quarterly basis . Bank reconciliation will be performed regularly; the city will utilize a third-part consultant to review these reconciliations. Training is being conducted by the third-party consultant and by the City Manager. The City will also strengthen its documentation retention policies to ensure all expenses are properly supported.

View Audit 390700

Finding 1176662 (2024-002)

Material Weakness 2024

Community Action Agency of Butte County, Inc.

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.302 § 200.303

Corrective Action Plan - Audit Finding 2024-002 Reportable finding considered a significant deficiency - Inadequate support for distribution of donated food 1. Documentation Procedures The Organization has updated its policies in 2025 to ensure all food distributions—including goods received, distri...

Corrective Action Plan - Audit Finding 2024-002 Reportable finding considered a significant deficiency - Inadequate support for distribution of donated food 1. Documentation Procedures The Organization has updated its policies in 2025 to ensure all food distributions—including goods received, distributed, used for on site meal preparation, and leftover items transferred to partner nonprofits—are supported by appropriate documentation. A standardized set of templates will be used to record: • Distribution logs at each location • Congregate Aggregate Feeding Reports • Documentation of leftover or transferred goods All documentation will be retained in a centralized repository accessible to program and compliance staff. ________________________________________ 2. Distribution Tracking Controls The Organization has implemented strengthened controls to ensure accurate and complete tracking of all food commodities. These controls include: • Required completion of distribution logs at all partner locations • Mandatory retention of Congregate Aggregate Feeding Reports • Reconciliation of monthly distribution activity to the Monthly Distribution Report • Documentation of discarded or transferred goods A compliance checklist is being developed to verify that all required documents are collected each month. ________________________________________ 3. Designation of Responsibility A Chief Operating Officer has been assigned responsibility for ensuring that all distribution documentation is collected, retained, and reviewed. Program staff and site partners will receive ongoing training to ensure consistent adherence to the updated tracking requirements. ________________________________________ 4. Review and Approval A formal review and approval process has been established. Monthly Distribution Reports will be reviewed by: • The Chief Operating Officer • The Warehouse Manager Any discrepancies or missing documentation will be investigated and resolved prior to monthly reporting. ________________________________________ 5. Monitoring and Follow Up Beginning in 2025, the Organization implemented ongoing monitoring procedures, including periodic internal audits of distribution files. Quarterly compliance reviews will be performed to assess adherence to documentation requirements and to identify additional training needs. The Warehouse Manager will report quarterly to senior leadership on distribution documentation compliance. Management will continue refining the new processes and providing ongoing training to ensure full, consistent adoption across all distribution sites. The Organization anticipates that these corrective actions will fully address the documentation gaps identified in the audit and strengthen internal controls moving forward. ________________________________________ Implementation Timeline All corrective action steps were initiated in 2025, and full implementation of updated procedures is ongoing. The Organization anticipates complete adoption across all distribution sites by December 31, 2026. ________________________________________ Responsible Personnel • Chief Operating Officer-Food Bank Operations: Thomas Deramore • Warehouse Manager-Food Bank Operations: Sean Conner • Chief Financial Officer: Kate Stefan • Executive Director: Timothy Hawkins ________________________________________ This Corrective Action Plan is designed to address the auditor’s findings, recommendations and prevent recurrence of similar issues to ensure compliance with Uniform Guidance documentation standards and internal control requirements ________________________________________ Signature: ________________________________________ Kate Stefan, Chief Financial Officer Community Action Agency of Butte County, Inc.

View Audit 390526

Finding 1176657 (2024-003)

Material Weakness 2024

Harrington Family Health Center

ME

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Finding: 2024-003 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $115...

Finding: 2024-003 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $115 but qualified for a discount of $215, resulting in a $100 difference. Individual(s) Responsible for Corrective Action: Tafta McCain, Interim CEO, Fraction CFO – Community Link Consulting, Financial Team Planned Corrective Action: The Organization has revised its sliding fee discount policies and has established controls that streamline the path of sliding fee documentation from time of receipt to patient notification in a spreadsheet shared between front office, financial and billing staff. All pertinent documents are uploaded and hyperlinked to the spreadsheet for easy reference. The corrective action includes implementing quarterly supervisory reviews of sliding fee discounts, defining a sample size, and documenting corrective actions when errors are identified. Additional attention will be given to areas with greater manual processing, including Dental services. Staff training has been reinforced to ensure understanding of policy requirements, and management oversight will verify that monitoring procedures are performed consistently and documented appropriately. These actions will strengthen compliance with Section 330 requirements and reduce the risk of future inconsistencies. Anticipated Completion Date: Document tracking is in progress with quarterly review to begin in April 2026.

View Audit 390525

Finding 1176656 (2024-002)

Material Weakness 2024

Harrington Family Health Center

ME

Internal Control / Segregation of Duties Reporting § 200.512 § 200.520

Finding: 2024-002 Condition Found: FAC filing for fiscal year ended March 31, 2024 was submitted late. Individual(s) Responsible for Corrective Action: Tafta McCain, Interim CEO, Fraction CFO – Community Link Consulting, Financial Team Planned Corrective Action: The late FAC filing was primarily the...

Finding: 2024-002 Condition Found: FAC filing for fiscal year ended March 31, 2024 was submitted late. Individual(s) Responsible for Corrective Action: Tafta McCain, Interim CEO, Fraction CFO – Community Link Consulting, Financial Team Planned Corrective Action: The late FAC filing was primarily the result of delays in finalizing financial statements and staff turnover. Executive leadership has addressed these issues through the corrective actions implemented under Finding 2024 001, including strengthened monthly close procedures and improved oversight of financial reporting timelines. The organization has also participated in financial technical assistance hosted by HRSA. In addition, the Organization has formalized responsibility for monitoring Single Audit and Federal Audit Clearinghouse deadlines within finance leadership, with executive level oversight to ensure compliance. The Organization has also retained a fractional CFO to provide continuity, expertise, and accountability on an ongoing basis. Management expects these actions to result in timely and compliant FAC submissions in future reporting periods. Anticipated Completion Date: Already completed with anticipated timely filing of FY 2026.

View Audit 390525

Corrective Action Plans

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