Corrective Action Plans

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Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that ...
Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. HAPCAP now has multiple staff that have been involved in the process of building audit reports. This will allow for timely audit completion for all future audits. We will also work with our audit firm to begin the work of the audit earlier in the calendar year for the 2023 audit. Contact Person Responsible for Corrective Action: Kelly Hatas, Executive Director Anticipated Completion Date: 10/24/2023 Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. Finding 2022-001: Late Filing of Audit Report Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. HAPCAP now has multiple staff that have been involved in the process of building audit reports. This will allow for timely audit completion for all future audits. We will also work with our audit firm to begin the work of the audit earlier in the calendar year for the 2023 audit. Contact Person Responsible for Corrective Action: Kelly Hatas, Executive Director Anticipated Completion Date: 10/24/2023
Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Manageme...
Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include the timely issuance of the financial statement and the uniform guidance report.
Finding 409 (2022-005)
Material Weakness 2022
Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: During testing, there were two debt covenants, net worth and the amount of capital expenditures, that w...
Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: During testing, there were two debt covenants, net worth and the amount of capital expenditures, that were not included in the monthly covenant report included in the financial packet for monitoring. There was also no control in place to seek approval prior to reaching the capital expenditure threshold of $100,000. Responsible Individuals: Nathan Johnson, CEO and Dan Stone, CFO Corrective Action Plan: We will update our monthly covenant report to include the net worth calculation and the amount of capital expenditures. We will actively seek lender approval prior to exceeding capital expenditures over $100,000. Anticipated Completion Date: December 31, 2023
Finding 408 (2022-004)
Significant Deficiency 2022
Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Re...
Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no formal documented review over the reserve fund reconciliation for the federal program. Responsible Individuals: Nathan Johnson, CEO and Dan Stone, CFO Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: August 31, 2023
Finding 406 (2022-003)
Material Weakness 2022
Federal Agency Name: U.S. Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 COVID‐19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Financial...
Federal Agency Name: U.S. Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 COVID‐19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: Eide Bailly LLP prepared our consolidated schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Responsible Individuals: Nathan Johnson, CEO Corrective Action Plan: Having auditors assist with preparing the consolidated schedule of expenditures of federal awards (Schedule) is not unusual. We will continue to be aware of the financial reporting requirements relating to PioneerCare’s consolidated schedule of expenditures of federal awards and internal control that impact financial reporting. Anticipated Completion Date: Ongoing
Finding 2022-002 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all ...
Finding 2022-002 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. Update: A Safe Place developed an infrastructure and implemented internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission
Finding 2022-001 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all ...
Finding 2022-001 – Reporting-Control and Compliance Finding Personnel Responsible for Corrective Action: CFO and Accounting department staff Anticipated Completion Date: September 2023 Corrective Action Plan: A Safe Place will implement internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission. Update: A Safe Place developed an infrastructure and implemented internal control procedures to ensure timely submission of all future reports. The CFO will review financial reporting prior to submission.
Finding 303 (2022-001)
Significant Deficiency 2022
Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the F...
Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the FSRS under the supervision of the Co-CEO. Anticipated completion date Within 30 days
Finding 299 (2022-002)
Significant Deficiency 2022
The city staff managing the business loan will receive training on the job duties, with oversight from the Sr. Revenue Manager. The city is monitoring each loan to ensure that we’re up-to-date with information, and remain in compliance with all necessary requirements of the loan program.
The city staff managing the business loan will receive training on the job duties, with oversight from the Sr. Revenue Manager. The city is monitoring each loan to ensure that we’re up-to-date with information, and remain in compliance with all necessary requirements of the loan program.
View Audit 552 Questioned Costs: $1
Penelope House, Inc. and CLAY Foundation, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Wilkins Miller, L.L.C. 41 West Interstate 65 Service Rd. North, Suite 400, Mobile, Alabama 36608. Aud...
Penelope House, Inc. and CLAY Foundation, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Wilkins Miller, L.L.C. 41 West Interstate 65 Service Rd. North, Suite 400, Mobile, Alabama 36608. Audit period: January 1, 2022 to December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING - COMBINED FINANCIAL STATEMENT AND FEDERAL AWARD FINDING 2022-001: Condition: The Organization reconciled significant accounts in the accounting system for December 31, 2022, with assistance by the auditing firm. The auditing firm’s assistance was overseen by an individual with the requisite skills, knowledge, and experience. However, reconciliations were not timely in that some reconciliations were not finalized until late September 2023. In addition, material adjustments were proposed and recorded by management during the audit to adjust accounts such as investments, grants and accounts receivable, accounts payable, and accrued expenses, and the related revenues and expenses, including adjustments of $80,942 to prior period balances and net assets. Additionally, errors in coding of transactions to the correct classes in the general ledger accounting software prevented the Organization from consistently implementing the control of comparing the grant draws and support to the general ledger detail. Criteria: Uniform Guidance 200.302(b)(4) states each non-federal entity must provide for “effective control over, and accountability for, all funds, property, and other assets.” Cause: Turnover in the CFO position twice during the year ended December 31, 2022, resulted in a time period where account reconciliations were not being maintained. The former CFO resigned effective March 2022, and her replacement resigned effective December 2022. This required extensive transition of knowledge that contributed to financial reporting delays. Effect: A material weakness in internal control over financial reporting and over compliance exists due to failure to properly code transactions and to timely reconcile and adjust accounts which led to material adjusting journal entries being identified during the audit process. Where the Organization maintained adequate documentation to support costs allowable for substantially the full amount of the budget for grant number HESG-CV-20-003 (CFDA 14.231), there was an isolated incident of errors in developing and communicating support for $78,932 of the draws.Recommendation: We recommend the Organization implement systems, procedures and training to ensure accounts are reconciled timely and accurately with the reconciliations completed entirely by the Organization’s accounting staff or by third party professionals prior to provision of the trial balance and supporting documentation to the auditor. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has developed and begun implementation of a corrective action plan. To address this finding, the Organization has implemented processes whereby the CFO compares profit and loss detail statements from the general ledger for each grant to the draw requests and investigates any differences. If the governing organization has questions regarding this plan, please contact me at 251-459-6665. Sincerely, Tonie Ann Coumanis Torrans Executive Director Penelope House, Inc. and CLAY Foundation, Inc.
Finding Reference Number: 2022-001 1. Name of the contact person responsible for corrective action Rachmiel Ungarischer, President 2. Corrective action planned Our Yeshiva has implemented procedures to review, analyze and reconcile the Yeshiva’s accounting records on a timely basis. 3. Anticipated c...
Finding Reference Number: 2022-001 1. Name of the contact person responsible for corrective action Rachmiel Ungarischer, President 2. Corrective action planned Our Yeshiva has implemented procedures to review, analyze and reconcile the Yeshiva’s accounting records on a timely basis. 3. Anticipated completion date The procedures will be implemented immediately. 4. If the client does not agree with the audit finding or believes corrective action is not required, include an explanation and specific reasons We agree with finding No. 2022-001
Finding 2022-002: Cash Management / Matching / Interest Earned Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and...
Finding 2022-002: Cash Management / Matching / Interest Earned Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and has created a new fund – Fund 07 – in the County’s accounting software and has begun creating corresponding revenue and expense accounts to match the existing structure within the new fund. The County also opened a separate checking account at The Juniata Valley Bank for the Children and Youth Fund for all revenue and expenses beginning January 1, 2024. The County continues to engage an external third-party contractor provider familiar with Children and Youth Agency financial matters to assist in the transition, as well as with recent turnover in the financial positions within the Children and Youth Department. The County also made the affirmative decision to capitalize that fund with the prior year’s County-match at the start of the calendar year and continue to fund, as needed, throughout the year to insure the necessary County match is attained. The Children and Youth Agency will continue to insure compatibility and proper recording in MUNIS, the County accounting system, of all financial transactions to match with the internal accounting system maintained by the Children and Youth Agency. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the engaged external service provider and the Children and Youth Finance Director and overall Child and Youth Agency Director to formulate the proper procedure for establishment of a separate fund balance as of January 1, 2024, and monitor proper posting of financial transactions in the appropriate fund to match all transactions posted in the internal accounting system maintained by the Children and Youth Agency. Date for Completion: January 1, 2024
To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The Co...
To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The County will also work with the pass-through grantor to develop an effective strategy to recruit and retain eligible out-of-school youth. The County will monitor the out-of-school services spending throughout the fiscal year and award period.
View Audit 240 Questioned Costs: $1
A NEW BUSINESS MANAGER WAS HIRED AND THE ROLE OF ASSISTANT BUSINESS MANAGER WAS ADDED TO THE ORGANIZATION. THE INCREASE IN BUSINESS OFFICE PERSONNEL WILL ALLOW FOR A MORE REALISTIC WORKLOAD. IN ADDITION, THE EXECUTIVE DIRECTOR WILL PROVIDE STRICTER OVERSIGHT IN ORDER TO ASSURE COMPLIANCE WITH GRAN...
A NEW BUSINESS MANAGER WAS HIRED AND THE ROLE OF ASSISTANT BUSINESS MANAGER WAS ADDED TO THE ORGANIZATION. THE INCREASE IN BUSINESS OFFICE PERSONNEL WILL ALLOW FOR A MORE REALISTIC WORKLOAD. IN ADDITION, THE EXECUTIVE DIRECTOR WILL PROVIDE STRICTER OVERSIGHT IN ORDER TO ASSURE COMPLIANCE WITH GRANT AGREEMENTS AND TIMELY COMPLETION OF THE SINGLE AUDIT REPORT
Finding 73 (2022-002)
Material Weakness 2022
Response and corrective action plan: Baker Places, Inc. concurs with the finding. Agency has hired additional financial staff and consulting resources in order to complete its annual audit and submission to the Federal Audit Clearinghouse (FAC) in a timely fashion. We anticipate that the FY 2022-23 ...
Response and corrective action plan: Baker Places, Inc. concurs with the finding. Agency has hired additional financial staff and consulting resources in order to complete its annual audit and submission to the Federal Audit Clearinghouse (FAC) in a timely fashion. We anticipate that the FY 2022-23 audit will be submitted to the FAC within the March 31, 2024 deadline (nine months after the end of our fiscal year). Anticipated completion date: March 31, 2024. Responsible person: Leo Levenson, Consulting CFO.
Finding 66 (2022-001)
Material Weakness 2022
The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient....
The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. For Economic Development loans an annual audit will be conducted June to ensure that the requirements of the grant are met. If audit finds any non-compliance issues are found three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. We will update our loan receivables listing to include a compliance check box which indicate that the loan is complying and actually a receivable at the end of the year.
View Audit 61 Questioned Costs: $1
The condition occurred due to the absence of a formalized reconciliation procedure to identify third-party reimbursements (e.g., insurance recoveries) prior to the compilation of federal expenditures reported in the SEFA. Corrective Measures, internal Control Enhancement, the Authority has revised i...
The condition occurred due to the absence of a formalized reconciliation procedure to identify third-party reimbursements (e.g., insurance recoveries) prior to the compilation of federal expenditures reported in the SEFA. Corrective Measures, internal Control Enhancement, the Authority has revised its SEFA preparation procedures to incorporate a formal reconciliation process between General Ledger federal expenditures, Third-party reimbursement records (including insurance recoveries), and Federal award financial reports. This reconciliation will be documented, reviewed by supervisory personnel within the Comptroller’s Office, and retained as part of the SEFA supporting documentation in accordance with record retention requirements under Uniform Guidance. Training and Capacity Development: Personnel responsible for grants accounting and SEFA preparation will complete additional training on 2 CFR Part 200 (Uniform Guidance), FEMA cost eligibility and documentation requirements, Identification and treatment of non-federal offsets to federal expenditures
Due to government closures that occurred during the pandemic it was impossible to obtain external and internal information to comply with established requirements.
Due to government closures that occurred during the pandemic it was impossible to obtain external and internal information to comply with established requirements.
Planned Corrective Action: Management agrees with the finding and has implemented controls to match revenue received from Emergency Federal Funds with expenditures submitted on drawdown requests. This will properly capture all expenditures of Federal Funds in the correct fiscal year. Furthermore, ma...
Planned Corrective Action: Management agrees with the finding and has implemented controls to match revenue received from Emergency Federal Funds with expenditures submitted on drawdown requests. This will properly capture all expenditures of Federal Funds in the correct fiscal year. Furthermore, management will meet on a quarterly basis to review all Federal Funds and perform reconciliations on a monthly basis. In addition to quarterly financial reviews and monthly financial reconciliations, management will immediately adapt to changing guidelines on Emergencv Federal Funds in future fiscal vears. Planned Implementation Date of Corrective Action: Currently Implemented.
The University will implement internal controls and procedures to ensure that the prevailing wage rate clause is included in all federally funded construction contracts in compliance with applicable regulations. The Principal Investigator (PI) will collaborate with Purchasing & Contracts (P&C) and t...
The University will implement internal controls and procedures to ensure that the prevailing wage rate clause is included in all federally funded construction contracts in compliance with applicable regulations. The Principal Investigator (PI) will collaborate with Purchasing & Contracts (P&C) and the Office of Sponsored Programs (OSP) on construction-related projects and will be responsible for flagging the prevailing wage requirement during the planning phase. The Purchasing Department will ensure the clause is included in all solicitations and bid packages for applicable projects. The Project Manager (PM) will be responsible to review all submitted bids to verify that minimum standards, including federal prevailing wage requirements, are met. Finally, the prevailing wage clause will be explicitly incorporated into the final contract and associated Purchase Orders (POs) to ensure full compliance with federal grant conditions and U.S. Department of Labor regulations. This process ensures consistency, accountability, and compliance across all units involved in construction.
Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evid...
Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evidence eligibility determinations, particularly during periods of increased service volume, to support accurate and allowable program charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action taken in response to finding: Effective 4/2022, management has taken deliberate steps to strengthen documentation and standardize eligibility determination and insurance verification processes. These efforts include the development and formalization of written policies and procedures to ensure consistent application, improved documentation standards, and sustained compliance with HRSA award requirements. Name(s) of the contact person(s) responsible for corrective action: James Washington, Executive Director and Bernie Soderberg, Program Manager. Planned completion date for corrective action plan: December 2023
As part of the preventive measures to file the Single Audit in a timely manner, an employee was selected to specifically dedicate time and effort related to auditing processes. Coordination of weekly meetings and phone calls with the external audit firm and the Programs has rendered immediate result...
As part of the preventive measures to file the Single Audit in a timely manner, an employee was selected to specifically dedicate time and effort related to auditing processes. Coordination of weekly meetings and phone calls with the external audit firm and the Programs has rendered immediate results to follow through with an established work plan. Therefore, time has been properly managed to collect the necessary information.
Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of i...
Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and subm...
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and submitted within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented formal reporting controls to ensure all required reports are prepared accurately, reviewed appropriately, and submitted within the required timelines. These controls include a structured reporting calendar with submission deadlines, assignment of responsibility for report preparation and review, and a standardized review and approval process prior to submission. The Organization has also developed documentation procedures to retain evidence of supervisory review, validation of key data points, and confirmation of timely submission. These enhancements are intended to reduce risk of late submissions and improve the accuracy and consistency of program reporting. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally re...
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
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