Corrective Action Plans

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2. System Controls: SCMRC’s accounting system was configured to require digital documentation of disbursement approvals. All disbursements are now traceable to authorized personnel.
2. System Controls: SCMRC’s accounting system was configured to require digital documentation of disbursement approvals. All disbursements are now traceable to authorized personnel.
3. Routine Oversight: The CEO and contract accountant conduct quarterly sampling of disbursement activity to verify proper documentation and authorization.
3. Routine Oversight: The CEO and contract accountant conduct quarterly sampling of disbursement activity to verify proper documentation and authorization.
4. Board Involvement: SCMRC’s Finance Committee reviews disbursement policies and internal controls annually as part of the broader fiscal oversight process.
4. Board Involvement: SCMRC’s Finance Committee reviews disbursement policies and internal controls annually as part of the broader fiscal oversight process.
5. Staff Training: Finance and administrative staff received updated training in 2024 on disbursement procedures and documentation protocols.
5. Staff Training: Finance and administrative staff received updated training in 2024 on disbursement procedures and documentation protocols.
1. SCMRC will conduct internal audits twice per year to verify continued compliance with disbursement approval and documentation requirements.
1. SCMRC will conduct internal audits twice per year to verify continued compliance with disbursement approval and documentation requirements.
2. A dashboard tracking disbursement approval timeliness and compliance will be developed in FY26 to support real-time monitoring.
2. A dashboard tracking disbursement approval timeliness and compliance will be developed in FY26 to support real-time monitoring.
3. The Controller will maintain a master log of all disbursement approvals and provide quarterly updates to the CEO.
3. The Controller will maintain a master log of all disbursement approvals and provide quarterly updates to the CEO.
4. SCMRC’s Disbursement Approval Policy will be reviewed and updated annually, with proposed revisions presented to the Finance Committee.
4. SCMRC’s Disbursement Approval Policy will be reviewed and updated annually, with proposed revisions presented to the Finance Committee.
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.
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