Corrective Action Plans

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5. Refresher training on approval protocols will be incorporated into the annual finance team training calendar beginning Q1 FY26.
5. Refresher training on approval protocols will be incorporated into the annual finance team training calendar beginning Q1 FY26.
1. All CMS-838 Credit Balance Reports for the audit period and subsequent quarters were submitted in September 2024 and accepted by CMS.
1. All CMS-838 Credit Balance Reports for the audit period and subsequent quarters were submitted in September 2024 and accepted by CMS.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
2. SCMRC updated its Medicare compliance protocols in 2025 and established centralized tracking of required federal reports in the CEO’s compliance calendar.
3. Ongoing Medicare reporting oversight has been assigned to the Controller, with CEO review and incorporation into Board-level financial and compliance workplans.
3. Ongoing Medicare reporting oversight has been assigned to the Controller, with CEO review and incorporation into Board-level financial and compliance workplans.
1. Maintain documentation of CMS guidance confirming discontinuation of the CMS-838 reporting requirement.
1. Maintain documentation of CMS guidance confirming discontinuation of the CMS-838 reporting requirement.
2. Continue centralized tracking of Medicare-related reporting requirements through the CEO’s compliance calendar.
2. Continue centralized tracking of Medicare-related reporting requirements through the CEO’s compliance calendar.
3. Ensure that changes in federal reporting requirements are verified, documented, and reviewed by the Controller and CEO.
3. Ensure that changes in federal reporting requirements are verified, documented, and reviewed by the Controller and CEO.
4. Reinforce Medicare compliance responsibilities in SCMRC’s financial and operational planning processes.
4. Reinforce Medicare compliance responsibilities in SCMRC’s financial and operational planning processes.
5. Conduct periodic internal reviews to ensure no reportable credit balances exist, even if formal reports are no longer required.
5. Conduct periodic internal reviews to ensure no reportable credit balances exist, even if formal reports are no longer required.
1. In 2024, SCMRC engaged CPA Zac Mabry to reconstruct and reconcile historical accounts payable balances, including verification of vendor-level detail.
1. In 2024, SCMRC engaged CPA Zac Mabry to reconstruct and reconcile historical accounts payable balances, including verification of vendor-level detail.
2. A new Controller was hired in April 2025 to oversee all general ledger and subsidiary ledger functions.
2. A new Controller was hired in April 2025 to oversee all general ledger and subsidiary ledger functions.
3. An Accounts Payable (A/P) Subsidiary Ledger was created and implemented in early 2025 using SCMRC’s accounting software.
3. An Accounts Payable (A/P) Subsidiary Ledger was created and implemented in early 2025 using SCMRC’s accounting software.
4. A/P balances are now reconciled monthly to the general ledger. Any discrepancies are documented and resolved prior to financial report finalization.
4. A/P balances are now reconciled monthly to the general ledger. Any discrepancies are documented and resolved prior to financial report finalization.
5. Internal procedures for invoice entry, approval, and payment were updated to require full detail (vendor, invoice #, date, and amount) for every payable.
5. Internal procedures for invoice entry, approval, and payment were updated to require full detail (vendor, invoice #, date, and amount) for every payable.
6. The reconciliation process is reviewed monthly by the CEO and contract accountant, and results are presented to the Finance Committee.
6. The reconciliation process is reviewed monthly by the CEO and contract accountant, and results are presented to the Finance Committee.
1. Continue maintaining a detailed subsidiary ledger for all accounts payable, updated in real time with invoice-level detail.
1. Continue maintaining a detailed subsidiary ledger for all accounts payable, updated in real time with invoice-level detail.
2. Ensure the Controller performs a monthly reconciliation of the A/P ledger to the general ledger, with documentation of any variances and resolutions.
2. Ensure the Controller performs a monthly reconciliation of the A/P ledger to the general ledger, with documentation of any variances and resolutions.
3. Incorporate A/P reconciliation procedures into SCMRC’s written accounting policy and procedure manual by October 2025.
3. Incorporate A/P reconciliation procedures into SCMRC’s written accounting policy and procedure manual by October 2025.
4. Implement a quarterly internal audit of A/P records to validate accuracy and completeness.
4. Implement a quarterly internal audit of A/P records to validate accuracy and completeness.
5. Provide annual refresher training for finance staff on internal controls, documentation standards, and reconciliation protocols.
5. Provide annual refresher training for finance staff on internal controls, documentation standards, and reconciliation protocols.
6. Evaluate the integration of A/P automation tools in FY26 to improve accuracy and audit trail capacity.
6. Evaluate the integration of A/P automation tools in FY26 to improve accuracy and audit trail capacity.
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