Corrective Action Plans

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Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
MATERIAL WEAKNESS Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management update its policies and procedures over distributions from surplus cash and ensure that the final audited calculation is utilized when making a di...
MATERIAL WEAKNESS Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management update its policies and procedures over distributions from surplus cash and ensure that the final audited calculation is utilized when making a distribution from surplus cash at year-end. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The surplus cash calculation used for the fiscal yearending 05/31/2025 inadvertently used the interim surplus cash calculation and not the final audited surplus cash calculation, which resulted in a slight overage in surplus cash distribution to its supporting charity organization. Once identified, provisions were made for immediate repayment, which was completed on 8/20/2026. The policy and procedure process was modified to ensure that the audited surplus cash calculation is used prior to any distribution. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa, Executive Director, Berkshire Retirement Home, Inc. DBA Berkshire Place, 290 South Street, Pittsfield, MA 01201 413-445-4056 #160; eforfa@berskhireplace.com Planned completion date for corrective action plan: 08/20/2026
Finding Number: 2026-002 Condition: The Organization did not appropriately monitor subrecipient audit findings to determine whether prompt and appropriate corrective action has been taken. Planned Corrective Action: The Organization has implemented system and process improvements to ensure review of...
Finding Number: 2026-002 Condition: The Organization did not appropriately monitor subrecipient audit findings to determine whether prompt and appropriate corrective action has been taken. Planned Corrective Action: The Organization has implemented system and process improvements to ensure review of subrecipient audit reports. To the extent that findings are identified, allowable mitigation measures will be considered by the Organization and documented as allowed under 2 CFR. The Organization has and will continue to maintain appropriate staffing level and sufficient training to ensure appropriate review is taking place. Contact Person Responsible for Corrective Action: Hannah Bonacci, Director, Public Partnerships Anticipated Completion Date: July 31, 2026
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training cont...
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training controls over the application of the sliding fee discount schedules. The Director of Patient Services (or designee) will perform monthly audits of 25 randomly selected patients accounts that received a sliding fee discount to verify that the correct discount schedule was applied and that the patient responsibility was calculated accurately. In addition, for any future changes to the sliding fee discount schedule, management will implement a transition review process that includes: • Verification that the updated fee schedule is accurately loaded into the billing system prior to the effective date and old fee schedules are inactivated. • Additional training for billing staff before implementation of any revised sliding fee schedule. • Continued monthly audits of sliding fee discounted patient accounts. • Quarterly reporting of audit results to Chief Financial Officer, to identify recurring issues and ensure corrective actions taken are effective. Anticipated completion date: July 31, 2026
In Finding 2026-002, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended March 31, 2026. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s ...
In Finding 2026-002, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended March 31, 2026. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2026-002, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.
The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a p...
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.
To Whom it May Concern, Orlando Rehabilitation Group, Inc. issued $8.0 million in grants during the fiscal year ending March 31, 2026. These grants were made to unaffiliated not-for-profit healthcare organizations. Orlando Rehabilitation Group, Inc., was unaware that these grants were not permitted ...
To Whom it May Concern, Orlando Rehabilitation Group, Inc. issued $8.0 million in grants during the fiscal year ending March 31, 2026. These grants were made to unaffiliated not-for-profit healthcare organizations. Orlando Rehabilitation Group, Inc., was unaware that these grants were not permitted to be made according to the structure of their HUD Mortgage. Kane Financial Services was also unaware. The plan to correct it includes the following action steps:  Seeking approval from HUD for the $8.0M in grants.  If the grant is not approved, then the Orlando Rehabilitation Group, Inc., will attempt to facilitate a re-payment plan over an extended period of time with the recipients of the grants. It is understood that such grants will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: SShain@kanefs.com Phone: 561-223-4161
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2026 Estimated Completion Date: June 2026 Finding #2026-001 – Statement of Condition Patients did not receive the proper sliding fee ad...
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2026 Estimated Completion Date: June 2026 Finding #2026-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding, and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Coordination with Revenue Cycle Management has occurred to ensure awareness across teams. Office Managers review all new sliding fee applications on a monthly basis to ensure accuracy, and the Billing Manager conducts quarterly audits of sliding fee claims to ensure adjustments are entered correctly by the billing department. The Organization also continues to provide staff training for all individuals involved in the sliding fee application process. Management has instructed all outsourced billers not to modify sliding fee adjustments; any required changes must be handled by in-house billing staff. Additionally, sliding fee adjustments auto posted in error will be removed. Management is also working with IT to restrict system access for outsourced users to prevent unauthorized adjustments. Additionally, IT will implement a scheduled monthly audit report to identify improper adjustments and monitor user activity.
Management has reviewed the audit finding and acknowledges the allegation related to improper administration of the applicant wait list. The former project manager is no longer with the Project, and management responsibilities have been reassigned. Management plans to review wait list procedures, st...
Management has reviewed the audit finding and acknowledges the allegation related to improper administration of the applicant wait list. The former project manager is no longer with the Project, and management responsibilities have been reassigned. Management plans to review wait list procedures, strengthen oversight and documentation requirements, and implement additional controls to ensure applicants are processed in accordance with established policies and applicable program requirements.
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discounts to certain patients who visited the Organization during the year ended March 31, 2026. In addition, sliding fee applications were not maintained for all patients who received sliding fee disco...
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discounts to certain patients who visited the Organization during the year ended March 31, 2026. In addition, sliding fee applications were not maintained for all patients who received sliding fee discounts. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2026-001, proper training will be given to employees and sliding fee applications and discounts will be reviewed by a supervisor on a monthly basis to ensure compliance with the sliding fee policy. The Organization will also establish procedures to ensure that sliding fee applications are maintained in accordance with the Organization’s policies.
Recommendation: The Center should develop policies and procedures to help ensure pay rates are consistent with supporting employee agreements or other management-approved documentation. Corrective Action Taken: 1. Immediate Review and Correction Upon identification of the finding, the Center conduct...
Recommendation: The Center should develop policies and procedures to help ensure pay rates are consistent with supporting employee agreements or other management-approved documentation. Corrective Action Taken: 1. Immediate Review and Correction Upon identification of the finding, the Center conducted a comprehensive internal audit of pay rates for all employees hired from January 1, 2025, to the present. Any discrepancies identified during this review were promptly corrected to ensure alignment with approved documentation. 2. Staff Training Targeted training will be provided to all Human Resources and Payroll staff. This training will emphasize: The importance of accuracy in data entry and the use of self-review as a quality control tool; Accountability at both the individual and team levels for maintaining complete and accurate payroll data; and Proper preparation and retention of documentation supporting initial payroll entries and any subsequent changes. 3. Policy and Procedure Review The Center has performed a comprehensive review of its internal policies and procedures to: Ensure clear delineation of roles and responsibilities across hiring, onboarding, and payroll processes; and Provide detailed guidance on required documentation to support each step in these processes. 4. Double-Verification Process Management has reinforced a culture of shared accountability by implementing a doubleverification process. This includes: Requiring staff to review and confirm the accuracy of their own work prior to submission; and Requiring receiving staff to independently verify information and resolve any discrepancies before proceeding with further processing. 5. Continued Monitoring In addition to standard bi-weekly payroll reviews conducted by management, the Center will implement quarterly payroll system audits. These audits will verify that all payroll changes are accurate, properly documented, and supported by appropriate approvals.
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the gr...
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has updated the grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. As part of this update management has reassigned responsibilities for various grants to ensure the process is followed.
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. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of this issue and meets regularly to discuss the workflows identified to minimize this issue until the vendor has implemented an interface to resolve this issue. The Organization has procedures in place to address the internal controls related to determining, recording, and monitoring the sliding fee process. The goal is to ensure that the appropriate sliding fee rates/categories are utilized for each encounter for each patient. The Organization has been working with the electronic health record vendor to interface the medical and dental components of the system to ensure the information is flowing across both components of the application. The sliding fee scale information is housed in the medical component of the system and does not consistently flow to the dental component of the system. The tentative go live date for this interface is scheduled for September 2026. Until then the team will continue to assess all dental sliding fee scale patients accounts manually to ensure accurate sliding fee rates/categories are utilized for each sliding fee encounter/patient.
S3800-045 ACTIONS TAKEN OR TO BE TAKEN: Management will endeavor to check files at the site level to ensure that the approval of each certification is retained on file. Management will work with the site managers and the compliance reviewing company to ensure accuracy of certifications, verification...
S3800-045 ACTIONS TAKEN OR TO BE TAKEN: Management will endeavor to check files at the site level to ensure that the approval of each certification is retained on file. Management will work with the site managers and the compliance reviewing company to ensure accuracy of certifications, verifications and rent calculations. The deficiencies found in the files audited will be corrected by Compliance and the site manager and reviewed by the Affordable Housing Director for completion and accuracy.
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
Material Weakness and Noncompliance: See Finding 2025-004. Recommendation: Management should establish formal grant acceptance and reporting procedures, including a reporting calendar, assigned preparer and reviewer responsibilities, documented supervisory review, reconciliation of reported amounts ...
Material Weakness and Noncompliance: See Finding 2025-004. Recommendation: Management should establish formal grant acceptance and reporting procedures, including a reporting calendar, assigned preparer and reviewer responsibilities, documented supervisory review, reconciliation of reported amounts to supporting records, and verification of timely submission. Action Taken: Prior to this finding, but subsequent to the audit period, the Credit Union established a formal grant management policy that defines roles, documentation standards, tracking procedures, reporting reconciliations, record retention, review and approval requirements, and periodic monitoring. The Credit Union considers all relevant requirements of Uniform Guidance, as well as specific requirements set forth in grant agreements and contracts. The Credit Union will maintain grant tracking records and reconcile grant activity to the general ledger and required award reports. Completion Date: July 28, 2026
Material Weakness and Noncompliance: See Finding 2025-003. Recommendation: Management should implement a grant review and approval acceptance process, grant reporting calendar and review process that reconciles reporting periods to the Credit Union's fiscal year, assigns preparer and reviewer respon...
Material Weakness and Noncompliance: See Finding 2025-003. Recommendation: Management should implement a grant review and approval acceptance process, grant reporting calendar and review process that reconciles reporting periods to the Credit Union's fiscal year, assigns preparer and reviewer responsibilities, documents review, and reconciles reported categories to the general ledger and supporting records before submission. Action Taken: Prior to this finding, but subsequent to the audit period, the Credit Union established a formal grant management policy that defines roles, documentation standards, tracking procedures, reporting reconciliations, record retention, review and approval requirements, and periodic monitoring. The Credit Union considers all relevant requirements of Uniform Guidance, as well as specific requirements set forth in grant agreements and contracts. The Credit Union will maintain grant tracking records and reconcile grant activity to the general ledger and required award reports. Completion Date: July 28, 2026
The District will strengthen its procedures for documenting time and effort for employees whose salaries or benefits are charged to federal or other restricted funding sources. Employees will be required to complete the appropriate time and effort documentation in a timely manner and in accordance w...
The District will strengthen its procedures for documenting time and effort for employees whose salaries or benefits are charged to federal or other restricted funding sources. Employees will be required to complete the appropriate time and effort documentation in a timely manner and in accordance with applicable grant requirements and District procedures. Financial Services, in coordination with the grant administrator and supervisors, will establish a process to monitor the submission and completion of time and effort records. Supervisors will review documentation for completeness and accuracy, and Financial Services will follow up on missing or late records. The District will provide guidance to employees and supervisors regarding time and effort requirements, including when documentation is required, who is responsible for completing and approving it, and the importance of submitting records timely. Documentation will be retained in an organized manner and made available for audit or monitoring purposes. Responsible Party: Financial Services Manager, Grant Administrator, and Supervisors Monitoring: Financial Services will periodically review time and effort records to ensure required documentation has been submitted, approved, and retained. Missing or untimely documentation will be followed up on and corrective action taken as necessary.
In response to this finding, management will take the following actions. 1. Adoption of the De Minimis Rate: The City will apply the 15% de minimis indirect cost rate, as permitted under Uniform Guidance, to applicable federal awards where a federally negotiated indirect cost rate agreement is not i...
In response to this finding, management will take the following actions. 1. Adoption of the De Minimis Rate: The City will apply the 15% de minimis indirect cost rate, as permitted under Uniform Guidance, to applicable federal awards where a federally negotiated indirect cost rate agreement is not in place. This approach will provide consistency in the recovery of indirect costs and ensure compliance with federal requirements. 2. Formalize Procedures: The Controller's Office will develop and document procedures governing the application of indirect cost rates, including guidance on when the de minimis rate may be used, calculation methodologies, required documentation, and approval requirements. 3. Training: Training will be provided to grants management, accounting, and program staff responsible for grant budgeting, financial reporting, and reimbursement requests to ensure a clear understanding of indirect cost rate requirements and the application of the minimis rate. 4. Management Oversight: The Controller's Office will establish a periodic review process to ensure the de minimis indirect cost rate is applied consistently, calculations are accurate, and adequate supporting documentation is maintained. Any discrepancies identified during the review process will be addressed timely to ensure compliance with Uniform Guidance requirements related to Indirect Cost Recovery.
As part of the closeout process for the City's remaining CARES Act grants, the Department of Grants and Community Development (DGCD) will work with HUD to ensure that Section 15011 reporting obligations are met and submitted prior to grant closeout. Additionally, DGCD has implemented amended interna...
As part of the closeout process for the City's remaining CARES Act grants, the Department of Grants and Community Development (DGCD) will work with HUD to ensure that Section 15011 reporting obligations are met and submitted prior to grant closeout. Additionally, DGCD has implemented amended internal controls that include Section 15011 requirements. To prevent similar issues from occurring with future federal awards, DGCD Program and Fiscal Operations managers will track reporting deadlines and maintain documentation evidencing submission, while the Compliance Division managers will perform periodic reviews to verify compliance with any nonstandard federal reporting requirements. These corrective actions will strengthen oversight of federal reporting requirements and ensure future grants are administered in accordance with all applicable federal regulations and award conditions.
The City of Atlanta’s Department of Grants and Community Development (DGCD) will establish and implement internal controls to ensure all relevant first-tier subawards are reported timely and accurately in accordance with FFATA requirements. Effective immediately, FFATA applicability will be evaluate...
The City of Atlanta’s Department of Grants and Community Development (DGCD) will establish and implement internal controls to ensure all relevant first-tier subawards are reported timely and accurately in accordance with FFATA requirements. Effective immediately, FFATA applicability will be evaluated during DGCD’s subrecipient contracting process. After the final action legislation but prior to contract execution, DGCD Program and Fiscal Operations staff will review all subawards to determine if FFATA reporting thresholds are applicable and document applicability in subaward files. DGCD staff will complete required FFATA submissions through SAM.gov by the end of the month following the month in which the subaward contract is executed. Additionally, DGCD Program and Fiscal Operations managers will conduct quarterly reviews of all active subrecipient agreements to verify compliance with FFATA requirements. Supporting documentation will be properly maintained in subrecipient files. DGCD will document reporting status, due dates, and completion dates in a standardized FFATA tracking log and checklist. DGCD’s Compliance Division will perform periodic oversight reviews to verify adherence to FFATA requirements and ensure corrective action is taken promptly if reporting deficiencies are identified. Additionally, the Controller’s Office will establish a periodic review process to ensure all City Departments are adhering to FFATA requirements.
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...
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 June 30, 2025. Mr. Benjamin Klein, executive director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-354-9500.
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