Corrective Action Plans

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We will ensure that the financial records are maintained on a current basis, reconciled timel and audited going forward.
We will ensure that the financial records are maintained on a current basis, reconciled timel and audited going forward.
Classification Material Weakness Responsible Official Chief Financial Officer Anticipated Completion Date December 31, 2026 Management Response Management concurs with the finding. OIC will formalize federal award tracking and SEFA preparation procedures to ensure federal expenditures are complete, ...
Classification Material Weakness Responsible Official Chief Financial Officer Anticipated Completion Date December 31, 2026 Management Response Management concurs with the finding. OIC will formalize federal award tracking and SEFA preparation procedures to ensure federal expenditures are complete, accurate, and readily identifiable by program. Corrective Action Plan 1. Assign grant codes and Assistance Listing Number identifiers within the accounting system to track federal expenditures by award, funding source, and program. 2. Prepare quarterly SEFA reconciliations to the general ledger, grant records, reimbursement requests, and supporting documentation. 3. Incorporate a SEFA preparation checklist into year-end closing procedures and submit the draft SEFA to the Audit Committee before audit fieldwork. Management will monitor corrective action progress and provide periodic updates to executive leadership, the Finance Committee, Audit Committee, and Board of Directors until all findings are remediated. Management believes these actions will strengthen internal controls, improve audit readiness, and reduce the risk of future findings.
Classification Material Weakness Responsible Official Chief Financial Officer and Chief Health Operations Officer Anticipated Completion Date March 31, 2027 Management Response Management concurs with the finding. OIC will strengthen revenue cycle controls to improve patient service revenue recognit...
Classification Material Weakness Responsible Official Chief Financial Officer and Chief Health Operations Officer Anticipated Completion Date March 31, 2027 Management Response Management concurs with the finding. OIC will strengthen revenue cycle controls to improve patient service revenue recognition, accounts receivable valuation, write-off governance, and billing system reconciliations. Corrective Action Plan 1. Transition from a flat encounter-based revenue estimate to a net realizable value methodology that incorporates contractual allowances, sliding fee discounts, implicit price concessions, and allowance for doubtful accounts. 2. Perform monthly documented reconciliations between EPIC, eClinicalWorks, Sage MIP, patient receivables, gross charges, adjustments, collections, write-offs, and general ledger balances. 3. Require documented management review and approval of accounts receivable aging, collectability analyses, write-offs impacting the general ledger, and revenue cycle dashboard reporting.
Management of The Agency for Substance Abuse Prevention, Inc. hereby submits the following corrective action plan in response to the single audit findings for the fiscal year ending September 30, 2025: Finding 2025-001 – Segregation of Duties: Description of Finding: The auditor found that duties we...
Management of The Agency for Substance Abuse Prevention, Inc. hereby submits the following corrective action plan in response to the single audit findings for the fiscal year ending September 30, 2025: Finding 2025-001 – Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
Views of Responsible Officials: Management acknowledges that a formal internal review and approval process over Federal drawdowns was not in place during the audit period, particularly for the more frequent drawdowns that moved from monthly to weekly. The change in drawdown practices, including perf...
Views of Responsible Officials: Management acknowledges that a formal internal review and approval process over Federal drawdowns was not in place during the audit period, particularly for the more frequent drawdowns that moved from monthly to weekly. The change in drawdown practices, including performing draws on a more frequent basis, was implemented in response to managing cash flow and external risks.Management notes that oversight was performed on a periodic basis, specifically each quarter end. Starting in May 2026, one financial party will calculate the Federal pull amount using actual costs and a 10% indirect rate, the Executive Director will review and sign off, and the Director of Grandfamilies & Kinship Support Network will initiate pulling funds from the Federal system.
Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the a...
Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 7/1/2026
1. Implementation of Formal Written Policy MCHA implemented a comprehensive Tenant File Review Policy and Procedure in November 2025. The policy: • Establishes mandatory monthly file review requirements • Defines standardized file selection methodology • Requires consistent documentation of all revi...
1. Implementation of Formal Written Policy MCHA implemented a comprehensive Tenant File Review Policy and Procedure in November 2025. The policy: • Establishes mandatory monthly file review requirements • Defines standardized file selection methodology • Requires consistent documentation of all reviews • Assigns clear roles and responsibilities for oversight and implementation • Requires reviews to be completed monthly without exception, regardless of workload or competing priorities 2. Review Frequency and File Selection • A minimum of 14 tenant files per month are reviewed: o 7 files from the prior month (retrospective review) o 7 files from the upcoming/proactive review group • Files are selected through a randomized process within Compliance Manager, ensuring: o Representation across annual reexaminations, interim reexaminations, and new admissions o A consistent and unbiased sampling of program activity 3. Standardized Review Procedures All file reviews are conducted using a uniform, HOTMA-compliant audit checklist, requiring verification of: • Income and asset calculations • Third-party verification documentation • Required HUD forms and signatures • Accuracy of subsidy determinations (TTP, HAP, utility allowance) • Proper application of payment standards and program requirements 4. Documentation and Internal Control Measures MCHA established a centralized internal tracking system (Excel-based) to document and monitor all file reviews and corrections. • The tracking log: o Is accessible to Case Managers for visibility o Has restricted editing access limited to the Compliance Manager and HCV Program Manager • The log includes: o File selected and review date o Identified deficiencies o Date file is submitted for audit o Date file is returned for correction o Date corrections are completed and formally signed off This process ensures: • A complete audit trail of all reviews and corrections • Separation of duties • Data integrity and accountability 5. Correction and Verification Process • All identified deficiencies must be corrected within established timeframes • Corrections may include: o File documentation updates o Participant or owner follow-up • No file is closed until: o Corrections are verified o Compliance is confirmed by management o Final sign-off is documented 6. Oversight and Accountability • The Program Manager is responsible for: o Overall oversight of the policy and procedures o Ensuring monthly compliance with review requirements o Confirming all deficiencies are resolved prior to closure • The Compliance Manager is responsible for: o Execution and implementation of the review process o Conducting detailed file audits o Maintaining and controlling the tracking log o Monitoring and documenting all correction activity This structure ensures clear segregation of duties, accountability, and consistent oversight. 7. Staff Training and Acknowledgment • All Case Managers received formal training in November 2025 • Each staff member signed a written acknowledgment confirming: o Receipt of the policy o Understanding of requirements • Documentation has been: o Provided to the auditors o Retained for compliance verification Status of Corrective Action Corrective actions were fully implemented in November 2025 and are currently in effect. Planned Completion Date Completed – November 2025 Responsible Officials • HCV Program Manager – Oversight and compliance monitoring • Compliance Manager – Implementation and audit execution Conclusion MCHA believes the corrective actions implemented fully address the identified deficiency. The Authority has established formal written policies, strengthened internal controls, and implemented a structured and sustainable monitoring process. These measures ensure: • Consistent and timely tenant file reviews • Documented tracking and accountability of corrections • Ongoing compliance with HUD program requirements MCHA is confident that these controls prevent recurrence of the issues identified in this finding.
Corrective Action Plan Program Managers responsible for submitting Performance Reports must copy the appropriate Contract Administrator, Director of Contracts, Accountability & Risk Management and the Director of Transition Services on all correspondence related to report submissions. When an extens...
Corrective Action Plan Program Managers responsible for submitting Performance Reports must copy the appropriate Contract Administrator, Director of Contracts, Accountability & Risk Management and the Director of Transition Services on all correspondence related to report submissions. When an extension is needed, the Program Manager will request written approval from TWC. If an unexpected delay occurs, the Program Manager will notify TWC in writing and confirm the anticipated submission date to support compliance with reporting deadlines. Program Managers will also create tasks and calendar reminders for all applicable reporting and billing due dates. Person(s) Responsible: Bekah Coggins, Director of Transition Services Anticipated Completion Date: Effective May 4, 2026, and onward
Corrective Action Plan In August 2025, Buckner updated billing policies and procedures related to reporting requirements. Each month, the Finance Administrator generates invoice and General Ledger reports that capture all transitions charged to the contract during the billing period. Because these r...
Corrective Action Plan In August 2025, Buckner updated billing policies and procedures related to reporting requirements. Each month, the Finance Administrator generates invoice and General Ledger reports that capture all transitions charged to the contract during the billing period. Because these reports reflect actual amounts posted to internal accounts rather than estimated expenditures, they are used to cross-reference program expenses and support billing submissions. Buckner also implemented additional levels of review to ensure the Program Manager completes billing documentation accurately, the Program Director reviews followed by final review by the Finance Administrator. Person(s) Responsible: Stefani Turner, Finance Administrator Bekah Coggins, Director of Transition Services Anticipated Completion Date Effective August 20, 2025, and onward
Corrective Action Plan In June 2025, Buckner began billing based on actual time worked to better align with state requirements. In January 2026, the Finance Administrator implemented a revised timecard template that requires supervisor time-stamped approval and includes protected formulas to calcula...
Corrective Action Plan In June 2025, Buckner began billing based on actual time worked to better align with state requirements. In January 2026, the Finance Administrator implemented a revised timecard template that requires supervisor time-stamped approval and includes protected formulas to calculate allocations and reduce errors. Each month, the Finance Administrator calculates allocations based on time worked, provides them to the Program Director for billing, and reviews state billing submissions to confirm accuracy. Person(s) Responsible: Stefani Turner, Finance Administrator Bekah Coggins, Director of Transition Services Anticipated Completion Date Effective June 20, 2025, and onward
View of Responsible Officials The Foundation is of the opinion that finding number 2025-001 for Cash Management is not applicable to the Equipment for Skilled Trades Training Programs as part of the Virginia Infrastructure Academy under ALN 84-116Z as requests for advance payments were limited to th...
View of Responsible Officials The Foundation is of the opinion that finding number 2025-001 for Cash Management is not applicable to the Equipment for Skilled Trades Training Programs as part of the Virginia Infrastructure Academy under ALN 84-116Z as requests for advance payments were limited to the minimum amounts needed and were timed with actual, immediate cash requirements to carry out the purpose of the approved programs and projects. With regards to College and Career Success for Foster Youth through Work-based Learning Opportunities and Coaching Support under ALN 84-116Z, the Foundation was notified by the U.S. Department of Education on September 12, 2024, that unused principal be returned. On September 25, 2024, the funds in the amount of $753,800 were refunded by wire transfer. This was the only notification the Foundation received from the U.S. Department of Education; no other notification was received regarding other advance payments made during the fiscal year. With regards to Improving the Quality of Early Childhood Educators under ALN 84-116Z, the Foundation did not receive any notification from the U.S. Department of Education requesting that advance payments be returned. In all instances of advance payments, the Foundation maintained funds in interest bearing accounts as outlined in the respective agreements for the three federal awards. With regards to the requests for advances that were made on a quarterly basis, the respective agreements for the three federal awards do not explicitly outline a timeframe for advance payments, nor did these advances trigger the federal government’s threshold for excessive drawdown. Estimated quarterly advance payments were made from the uncertainty of the U.S. Department of Education clawing back award funding while ensuring sufficient cash on hand to support approaching distributions to students and colleges and mitigating risk to the Foundation covering respective distributions with its own funds. Brown Edwards shared the suggested interpretation is a one-to-three-day timeframe between drawdown and distribution. Action taken: The Foundation calculated advance payment balances as of November 4, 2025, and issued respective returns to the U.S. Department of Education on November 5, 2025. Subsequent drawdowns have been made on a reimbursement basis. Action planned: The Foundation will revise its policies and procedures for requesting federal funds to ensure that requests for advance payments be limited to the minimum amounts needed and be timed with actual, immediate cash requirements to carry out the purpose of approved programs and projects. Specific steps: The Foundation will develop and implement a written policy requiring a documented review of immediate cash needs before any federal fund drawdown request is submitted and establishing a process to request funds on a reimbursement basis or just-in-time advance basis to align drawdowns with actual disbursements. Responsibility: The Chief Operating Officer and Finance Manager will work to draft the policy and will bring it to the Audit Committee for review and approval. Timeline: Policy approved and implemented by February 2026.
Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Plan, Uniform Guidance and the compliance supplement. Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the audito...
Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Plan, Uniform Guidance and the compliance supplement. Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies included within the Plan are being followed. Daniel Lyons, Executive Director, is responsible for implementing this corrective action by June 30, 2026.
At the start of each fiscal year, the Finance Director will prepare a submission timeline working backward from the March 31 FAC deadline, establishing interim milestones for year-end close, draft financial statement preparation, management review, and auditor fieldwork. Progress against the submiss...
At the start of each fiscal year, the Finance Director will prepare a submission timeline working backward from the March 31 FAC deadline, establishing interim milestones for year-end close, draft financial statement preparation, management review, and auditor fieldwork. Progress against the submission timeline will be monitored by the CEO and reported to the Board of Directors on a quarterly basis. Management will engage its external auditors earlier in the process and ensure adequate finance staffing is maintained prior to the fiscal yearend close.
Finding 1217738 (2025-003)
Material Weakness 2025
Finding 2025-003 – Untimely Return of Security Deposits Name of contact person: Lisa Fischer, (Chief Operating Officer) Corrective action: Management agrees with the finding and has implemented procedures to monitor tenant move-outs, document amounts due to former tenants, and issue refund checks in...
Finding 2025-003 – Untimely Return of Security Deposits Name of contact person: Lisa Fischer, (Chief Operating Officer) Corrective action: Management agrees with the finding and has implemented procedures to monitor tenant move-outs, document amounts due to former tenants, and issue refund checks in a timely manner. Proposed completion date: Management has corrected the finding.
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit f...
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2026
Findings #2025-004 and #2025-006 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 –...
Findings #2025-004 and #2025-006 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA RSS, 10/01/24 – 09/30/25, FFY2025-27946V-AUSAA-RSS, 10/01/24 – 09/30/25, FFY2025-27946V-CMA, 10/01/24 – 09/30/25, FFY2025-27946V-RSS, Passed through United States Conference of Catholic Bishops: 10/01/24 – 09/30/25, 25RSI13A, Passed through U. S. Committee for Refugees: 10/01/24 – 09/30/25, RHP-2025-YMCA-Houston TX-03, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG, 93.676, Unaccompanied Alien Children Program, Passed through U. S. Committee for Refugees and Immigrants: 01/01/25 – 12/31/25, 90ZU0630-02. Condition and context: During our testing of the accuracy of accounts payable cutoff and the testing of allowable costs charged to major programs, the following exceptions were identified for expenses recorded in the incorrect period: 3 of 19 subsequent disbursement transactions tested were recorded in the incorrect accounting period. Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 3 out of 40 transactions tested were recorded to the incorrect accounting period. Unaccompanied Alien Children Program (ALN 93.676) – 1 out 40 transactions tested was recorded in the incorrect accounting period. Refugee and Entrant Assistance Voluntary Agency Programs (ALN 93.567) – 1 out of 40 transactions tested was recorded in the incorrect accounting period. Recommendation: Policies and procedures should be enhanced for proper identification of the period that expenses relate to so that expenses will be recorded in the correct accounting period for financial statement reporting and for billing allowable costs to federal programs. Planned corrective action: Management acknowledges the deficiency identified related to the precision of procedures to ensure expenses are recorded in the appropriate accounting period. Processes were in place and operated to identify and record expenses in the correct period, and management’s review procedures are designed to capture all material items for financial reporting and program compliance purposes. The exceptions identified through audit testing represent a limited number of timing differences in a high-volume environment, primarily related to the timing of invoice receipt and processing, and were not material individually or in the aggregate. These items were recorded in the subsequent period in the normal course of operations and do not reflect a systemic breakdown in controls. In response, management has reinforced month-end cutoff procedures, including enhanced review of subsequent disbursements and clearer expectations around accrual identification and invoice timing. Management will continue to monitor cutoff procedures to ensure expenses are recorded in the appropriate period with an appropriate level of precision while maintaining timely vendor payment practices. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: June 15, 2026
Findings #2025-001 and #2025-005 – Material Weakness. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA...
Findings #2025-001 and #2025-005 – Material Weakness. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA RSS, 10/01/24 – 09/30/25, FFY2025-27946V-AUSAA-RSS, 10/01/24 – 09/30/25, FFY2025-27946V-CMA, 10/01/24 – 09/30/25, FFY2025-27946V-RSS, Passed through United States Conference of Catholic Bishops: 10/01/24 – 09/30/25, 25RSI13A, Passed through U. S. Committee for Refugees: 10/01/24 – 09/30/25, RHP-2025-YMCA-Houston TX-03, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG, 93.676, Unaccompanied Alien Children Program, Passed through U. S. Committee for Refugees and Immigrants: 01/01/25 – 12/31/25, 90ZU0630-02. Condition and context: During the planning phase of the audit, management disclosed that amounts reported as employee withholdings on Form 941 had been intentionally manipulated by the former payroll director resulting over reporting withholdings to the Internal Revenue Service. Management did not have a formal reconciliation process in place to compare Form 941 to the payroll register and general ledger, nor was there a periodic reconciliation of the payroll register to the general ledger. The absence of these independent reconciliation controls allowed the misstatement to occur and not be detected in a timely manner. In our testing of 110 payroll transactions, we identified the following exceptions: Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 1 out of 40 payroll transactions tested utilized the incorrect pay rate. Unaccompanied Alien Children Program (ALN 93.676) – 1 out of 40 payroll transactions tested utilized the incorrect pay rate. Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 1 out of 40 payroll transactions tested was incorrectly charged to the program. Additionally, in testing the reconciliation of payroll expense recorded in the payroll register to the amount recorded in the general ledger system, an error of $349,000 was identified. The error was related to credit card charges erroneously being recorded to payroll expense. Recommendation: Policies and procedures should be designed and implemented to prepare a formal reconciliation of Form 941 to the payroll register and the general ledger and a reconciliation between the payroll register and the general ledger. Additionally, procedures should be strengthened over the review of pay rates utilized in the payroll system and the allocation of payroll to cost centers and government programs. Planned corrective action: Management acknowledges the deficiency identified in the execution and precision of payroll reconciliation processes. During the audit planning phase, management disclosed that a former payroll director intentionally manipulated employee withholding amounts reported on Form 941 in prior periods. While reconciliation procedures between the payroll register, general ledger, and Form 941 filings were in place, they were not performed with sufficient precision and consistency to detect the misstatement in a timely manner. Additionally, audit testing identified isolated instances of incorrect payrates and program allocations, as well as a misclassification of approximately $349,000 related to credit card return charges recorded to accrued payroll; management has confirmed this item represents a classification error and not an issue impacting payroll processing or employee compensation. In response, management has refined reconciliation procedures to require more detailed comparison across systems, established clearer expectations for investigation and resolution of variances, and enhanced documentation standards to evidence the level of review performed. Management has also strengthened oversight of payroll activity, including review of payrates and allocation of payroll costs to programs, and will continue to monitor these controls to ensure they are operating with an appropriate level of precision and consistency. In May 2026, an interim leadership structure was established in response to the departure of the Chief Financial Officer. During this interim period management is assessing departmental functions and organizational structure to better align responsibilities and further strengthen internal controls in the areas noted above. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: June 15, 2026.
Finding Number: 2025-005 Planned Corrective Action: Management is implementing additional review and validation procedures for UDS reporting. Corrective actions include formal UDS preparation and review protocols, standardized validation checklists, retention of supporting documentation, and annual ...
Finding Number: 2025-005 Planned Corrective Action: Management is implementing additional review and validation procedures for UDS reporting. Corrective actions include formal UDS preparation and review protocols, standardized validation checklists, retention of supporting documentation, and annual training for personnel responsible for preparing and reviewing HRSA reports. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Charles Tong, Chief Financial Officer
Finding Number: 2025-004 Planned Corrective Action: Management has already begun to implement corrective actions to strengthen compliance with HRSA Sliding Fee Discount Program requirements. Corrective measures include updating sliding fee procedures, annual staff training, monthly quality assurance...
Finding Number: 2025-004 Planned Corrective Action: Management has already begun to implement corrective actions to strengthen compliance with HRSA Sliding Fee Discount Program requirements. Corrective measures include updating sliding fee procedures, annual staff training, monthly quality assurance reviews, and ongoing management oversight of sliding fee adjustments and supporting documentation. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Charles Tong, Chief Financial Officer
Training for all Medicaid staff on correct determination of income, resources, ownership, household composition, proper verification requests (clarity and completeness), and timely processing of recertifications. Ongoing Quality Assurance Second-party reviews will continue to ensure compliance with ...
Training for all Medicaid staff on correct determination of income, resources, ownership, household composition, proper verification requests (clarity and completeness), and timely processing of recertifications. Ongoing Quality Assurance Second-party reviews will continue to ensure compliance with Medicaid policy and to catch errors in real time. Starting in 2026, the agency will conduct mandatory quarterly training sessions focused on accuracy, policy updates, and lessons learned from reviews and audits.
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was no...
Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was not consistently documented for compliance-related transactions. As a result, review procedures appear to be informal, inconsistent, or reliant on individual practices rather than standardized, documented controls. Management Response and Corrective Action Plan: Management agrees with the recommendation and has developed a much more stringent review and approval process. Responsibility of: Chief Finance and Admin Officer, Sherri Emitte Planned Implementation Date of Corrective Action Plan: 2026 Audit
Adeline Montessori School will establish a policy for recording, safeguarding, and maintaining property and equipment purchased with federal funding.
Adeline Montessori School will establish a policy for recording, safeguarding, and maintaining property and equipment purchased with federal funding.
Adeline Montessori School will establish a policy for not entering into a contract with a party that is suspended or debarred and follow this policy for future purchases.
Adeline Montessori School will establish a policy for not entering into a contract with a party that is suspended or debarred and follow this policy for future purchases.
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