Corrective Action Plans

Finding 573159 (2024-001)

Material Weakness 2024

NJ

Student Financial Aid Subrecipient Monitoring Cash Management

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing th...

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing the manual intervention so that the issues preventing the Pell disbursement from being recorded on COD is reduced. We are adding automation for processing: FABATCH, ATB automation, and Citizenship automation.

View Audit 363978

Finding 573158 (2024-003)

Significant Deficiency 2024

Hawaiian Shores Community Association

HI

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit fi...

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Association will make the required transfers in fiscal year 2025 to ensure compliance with loan requirements. Name of the contact person responsible for corrective action: Jeff Sargent Planned completion date for corrective action plan: May 1, 2025

View Audit 363975

Finding 573124 (2024-001)

Significant Deficiency 2024

West Michigan Regional Medical Consortium

MI

Allowable Costs / Cost Principles Reporting Significant Deficiency

West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2024 Organization Contact Person: Jerry Evan...

West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2024 Organization Contact Person: Jerry Evans, MD; Medical Director The findings from the September 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding ‐ Federal audit Finding 2024‐001 ‐ Significant Deficiency Recommendation: West MI Regional Medical Consortium currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Action to be Taken: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.

View Audit 363935

Finding 573121 (2024-001)

Material Weakness 2024

The Addiction Center of Broome County, Inc.

NY

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal proces...

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal processes will be adjusted as needed. We will continue to monitor this area and document efforts to ensure ongoing alignment with applicable regulations. Contact Person Responsible for Corrective Action Plan: Lottie Albrecht, Director of Administration Phone Number: 607-940-0102 Email: lalbrecht@acbcservices.org Anticipated Completion Date of Corrective Action Plan: December 2025 (as part of preparation for fiscal year ending December 31, 2025)

View Audit 363928 Questioned Costs: $1

Finding 573115 (2024-002)

Material Weakness 2024

Genesee County Youth Corporation

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursemen...

2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursements. Additionally, the Business Operations Manager and Executive Director will implement a systematic review of all grant awards, contracts, and develop an addendum document charting all allowable expenses within each funding stream that will be utilized by the team when to determine proper allocation of disbursements. This chart will provide a quick guide to monitor compliance and allow-ability of expenditures to each funder at the time a check request is submitted. Checks

View Audit 363925 Questioned Costs: $1

Finding 573049 (2024-002)

Significant Deficiency 2024

Kewaunee County, Wisconsin

WI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to ...

Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to determine where additional enhancements should be made or new policies created, a plan to communicate these policies to County employees, and procedures to periodically review and update, as considered necessary. Action Planned/taken in response to the finding: Kewaunee County agrees with the finding. An assessment of all grants, requirements, and related policy and procedures is in progress and will continue to:  Evaluate existing policy and procedures for needed revisions  Document revisions to policy and procedures as necessary  Communicate any new policies to employees responsible for awards  Identify awards covered by the Uniform Guidance  Set and document a schedule for periodic review and revision Policy and procedures, as well as related documentation, are being revised as necessary to ensure compliance with the Uniform Guidance. Progress continues into 2024. The Finance Director will continue to coordinate and provide assistance and guidance to departments receiving grants subject to the Uniform Guidance. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh Planned completion date for corrective action: December 31, 2025

View Audit 363924

Finding 573043 (2024-003)

Significant Deficiency 2024

Kewaunee County, Wisconsin

WI

Cash Management Reporting Significant Deficiency

Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing tra...

Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing transitions in fiscal year 2025 to ensure that proper review of claim forms and expenditure reconciliation. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh and Brian Johnson Planned completion date for corrective action: December 31, 2025

View Audit 363924

Finding 573040 (2024-002)

None 2024

The Chamber Foundation

ND

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.331

Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation has subsequently requested all audit reports from all subrecipients. Addi...

Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation has subsequently requested all audit reports from all subrecipients. Additionally, the Chamber Foundation has changed subaward formatting to ensure that all required information is included within the award. Planned implementation date of corrective action: Ongoing

View Audit 363920

Finding 573036 (2024-001)

Material Weakness 2024

Banner Health

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reve...

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reverse invoices’ using the time tracked in Banner’s timekeeping system by contract labor resources and presents those hours/dollars to contract labor agencies for approval prior to remitting payment to those agencies. These invoices are reviewed by Banner’s staffing services team for reasonableness prior to being presented to the agencies for approval. There is an expectation that managers review and formally approve the timecards of contract labor resources in the timekeeping system, however, the reverse invoicing process moves forward even in the absence of a documented formal approval. Banner will implement a periodic monitoring process that provides a report of ‘forced sign offs’ (timecards without documented manager approval) to senior leadership in an effort to increase compliance with the timecard approval policy. Contact: Paul Nolde-Morrissey, Vice President and Corporate Controller Expected completion date: September 30, 2025

View Audit 363912

Finding 573035 (2024-002)

Significant Deficiency 2024

Warren County, Missouri

MO

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.

View Audit 363908

Finding 573032 (2024-001)

Material Weakness 2024

Ncsc/usa Housing Development Corporation Two

FL

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University D...

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement stronger internal controls over the administration of tenant eligibility and file maintenance, inclusive of more rigorous staff training, to ensure HUD regulations are followed timely and accurately. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting, tenant file maintenance, and monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO

View Audit 363899

Finding 573029 (2024-009)

Material Weakness 2024

City of Nogales Arizona

AZ

Special Tests & Provisions Procurement, Suspension & Debarment Material Weakness § 200.303 § 200.326

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: ...

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: There was no support provided for the three out of three contractor vendors with construction work noted on their purchase orders to support compliance with Davis Bacon. Corrective Action Plan: Regarding the wage tests for the Park’s grant, no information was provided to the City from the contractor of employee wages paid by the contractor. An email request and answer from the contractor was forwarded to the auditors, that the contractor was not responsible to report the wages. This in the future will be part of the Grants Coordinator position for Internal Control purposes, to ensure that any future construction contracts include the wage reporting requirements. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager

View Audit 363891

Finding 573028 (2024-008)

Material Weakness 2024

City of Nogales Arizona

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

2024 – 008 – Reporting Federal Agency: Department of the Treasury Department of Interior Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds (ARPA) Outdoor Recreation Acquisition, Development and Planning ALN: 21.027 15.916 Pass-Through Agency: Coronavirus State and Local ...

2024 – 008 – Reporting Federal Agency: Department of the Treasury Department of Interior Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds (ARPA) Outdoor Recreation Acquisition, Development and Planning ALN: 21.027 15.916 Pass-Through Agency: Coronavirus State and Local Fiscal Recovery Funds (ARPA) N/A Outdoor Recreation Acquisition, Development and Planning Arizona State Park Trails Pass-Through Number(s): Coronavirus State and Local Fiscal Recovery Funds (ARPA) N/A Outdoor Recreation Acquisition, Development and Planning 04-007-652304 Award Number and Period: Coronavirus State and Local Fiscal Recovery Funds (ARPA) 1505-0271 3/3/2021 – 12/31/2024 Outdoor Recreation Acquisition, Development and Planning 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) (ARPA) - Audit procedures included testing the SLFRF Compliance Report. During the testing of the Compliance report, it was noted that the report’s key line items below were not properly supported: • Current period expenditure • Cumulative expenditure Current period expenditures per the Compliance Report was $-0- and per the expenditure details provided were $907,419 creating a difference of $907,419. Cumulative expenditures per the Compliance Report was $6,714,003 and per the expenditure details provided were $4,264,421 creating a difference of $2,449,582. Outdoor Recreation Acquisition, Development and Planning - Audit procedures included selection and testing of two quarterly reports. Two out of two of the quarterly reports tested contained no separate reviewer/approver support. FEDERAL AWARD FINDINGS (Continued) 2024 – 008 – Reporting (Continued) Corrective Action Plan: The City concurs with this finding. With the addition of the Grants Coordinator, all reporting of all departments will be filtered through this position. The City also will use an outside Grants consultant to help research, apply, and coordinate the City’s grants in entirety. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager

View Audit 363891

Finding 573021 (2024-003)

Material Weakness 2024

City of Johnstown

PA

HUD Housing Programs Material Weakness Reporting

The City will work to develop a listing of report submission deadlines as well as cross training staff as appropriate.

View Audit 363889

Finding 573008 (2024-001)

Significant Deficiency 2024

Early Learning Coalition of Florida's Heartland, INC

FL

Reporting Significant Deficiency Internal Control / Segregation of Duties

SEE CORRECTIVE ACTION PLAN AT PDF PAGE 32 OF THE SUBMITTED AUDITED FINANCIAL STATEMENTS

View Audit 363875

Finding 573007 (2024-003)

Material Weakness 2024

Southwest Center for Hiv/aids, INC

AZ

Cash Management Material Weakness Reporting

Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement:...

Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement: Per the grant agreements, award recipients are required to submit monthly reimbursement report within a set number of days after month end. Condition: Financial reimbursement reports were submitted after the required due date. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will submit required reports timely going forward.

View Audit 363873

Finding 572993 (2024-002)

Significant Deficiency 2024

La Clinica Tepeyac

CO

Cash Management Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

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 approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with...

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 approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed all our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering the accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a draw down can be requested in the payment management system. This new process to ensure the documented approval of federal fund drawdown's was implemented mid-year 2024, after the three selections in this finding were completed.

View Audit 363862

Finding 572992 (2024-001)

Material Weakness 2024

La Clinica Tepeyac

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

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/categori...

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 made changes to improve the process and procedure based on the 2023 audit finding, but they were not implemented until midyear 2024 based on the completion of the audit. It is expected that 100% improvement in findings would not take place with this late implementation. There was an improvement over the prior year, especially in the lack of documentation on file. The monthly audit process to spot check applications for accuracy and ensure complete documentation in the chart was also implemented mid-year in 2024.

View Audit 363862

Finding 572979 (2024-001)

Significant Deficiency 2024

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditure...

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.

View Audit 363843 Questioned Costs: $1

Finding 572973 (2024-001)

Significant Deficiency 2024

Open Doors for Multicultural Families

WA

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospect...

We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospective contractors will be entered into the Sam system and scanned for debarment prior to contracting with them by the Program Manager. In addition, we are in the process of updating our vendor agreements to include language so a vendor can attest they are not debarred from doing business with the federal government.

View Audit 363824

Finding 572971 (2024-002)

Material Weakness 2024

City of Marshalltown

IA

HUD Housing Programs Material Weakness Reporting § 200.303

Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified i...

Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified in which the City did not use accurate financial information or retain evidence to document the individual who reviewed the Voucher Management System (VMS) reports prior to submission. Responsible Individual: Diana Steiner, Finance Director Corrective Action Plan: We agree with the auditor’s recommendation and staff will have asecond person review the reports. Anticipated Completion Date: By the completion of the ACFR for the fiscal year ending June 30, 2025.

View Audit 363814

Finding 572967 (2024-003)

Material Weakness 2024

Usd #272, Cawker City, Kansas

KS

Internal Control / Segregation of Duties

Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold requi...

Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold required by Uniform Guidance.

View Audit 363796

Finding 572963 (2024-001)

None 2024

Beacon Health System, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.

View Audit 363788

Finding 572940 (2024-002)

Significant Deficiency 2024

Presbyterian Medical Services

NM

Reporting Significant Deficiency Internal Control / Segregation of Duties

Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, D...

Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, Director of Finance. Estimated Completion Date: May 15, 2025

View Audit 363780

Finding 572939 (2024-001)

Significant Deficiency 2024

Presbyterian Medical Services

NM

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Au...

Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Audits by location will be carried out by CBO staff and financial analysts, with results shared with administrators and CARs for accountability. Clinics showing minimal improvement will receive additional training. Two mandatory sliding fee scale training sessions will be schedules for all CARs, accounts receivable staff, and administrators. Persons Responsible: Steven Hansen, President & CEO; Peral Lujan, Central Billig Office Director Estimated Completion Date: December 31, 2025

View Audit 363780

Corrective Action Plans

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