Corrective Action Plans

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1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and...
1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and informal review procedures that were not consistently documented. Following organizational restructuring and personnel transitions, management has begun a broader effort to formalize and strengthen compliance monitoring, supervisory review procedures, and documentation practices across our housing portfolio. b. Action(s) Taken or Planned on the Finding: 1. Monthly Compliance and Financial Oversight Meetings: We are establishing recurring monthly oversight meetings with executive leadership, finance, and housing management personnel to review financial reporting, reserve activity, compliance requirements, tenant-related matters, and operational performance. We plan to document these meetings and retain evidence of supervisory review as part of our compliance monitoring procedures. 2. Expanded Finance and Compliance Oversight Structure: We have added a Director of Housing and Compliance responsible for operational and regulatory compliance oversight and have contracted an Interim CFO who is a licensed CPA. We plan to continue refining roles and further segregating responsibilities among the accounting, compliance, and operational functions to strengthen internal controls and management review. 3. Formalized Compliance Monitoring Procedures: We are developing standardized compliance monitoring procedures, including monthly reserve deposit tracking, supervisory review checklists, documented financial statement review procedures, reconciliation monitoring, and periodic compliance checklists addressing key HUD program requirements. 4. Ongoing Monitoring and Documentation Retention: We will strengthen documentation retention procedures so that evidence of compliance monitoring, supervisory review, and reconciliation activities is consistently maintained and available for future audits and regulatory reviews. c. Anticipated Completion Date: Full implementation is expected to be completed and documented by March 31, 2027.
1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and...
1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and informal review procedures that were not consistently documented. Following organizational restructuring and personnel transitions, management has begun a broader effort to formalize and strengthen compliance monitoring, supervisory review procedures, and documentation practices across our housing portfolio. b. Action(s) Taken or Planned on the Finding: 1. Monthly Compliance and Financial Oversight Meetings: We are establishing recurring monthly oversight meetings with executive leadership, finance, and housing management personnel to review financial reporting, reserve activity, compliance requirements, tenant-related matters, and operational performance. We plan to document these meetings and retain evidence of supervisory review as part of our compliance monitoring procedures. 2. Expanded Finance and Compliance Oversight Structure: We have added a Director of Housing and Compliance responsible for operational and regulatory compliance oversight and have contracted an Interim CFO who is a licensed CPA. We plan to continue refining roles and further segregating responsibilities among the accounting, compliance, and operational functions to strengthen internal controls and management review. 3. Formalized Compliance Monitoring Procedures: We are developing standardized compliance monitoring procedures, including monthly reserve deposit tracking, supervisory review checklists, documented financial statement review procedures, reconciliation monitoring, and periodic compliance checklists addressing key HUD program requirements. 4. Ongoing Monitoring and Documentation Retention: We will strengthen documentation retention procedures so that evidence of compliance monitoring, supervisory review, and reconciliation activities is consistently maintained and available for future audits and regulatory reviews. c. Anticipated Completion Date: Full implementation is expected to be completed and documented by March 31, 2027.
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have adequate internal controls to ensure that the FFATA reporting requirements were completed in ac...
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have adequate internal controls to ensure that the FFATA reporting requirements were completed in accordance with the grant agreement, and within the timeframe required. Corrective Action Plan: We will implement internal controls over FFATA reporting to ensure that all reportable first-tier subawards are appropriately identified, evaluated for reporting requirements, and submitted in SAM.gov accurately and within the required reporting timeframe. Responsible Individuals: David Whipps, CFO, and Kurt Waldbillig, CEO Anticipated Completion Date: 12/31/2026
2026-001 Period of Performance Corrective action planned: The organization will implement an additional step to review personnel cost categories that may have the potential of including out-of-period costs (e.g., performance bonus payments, contractual lump sum payments) and verify that these expens...
2026-001 Period of Performance Corrective action planned: The organization will implement an additional step to review personnel cost categories that may have the potential of including out-of-period costs (e.g., performance bonus payments, contractual lump sum payments) and verify that these expenses are allocated to the correct award cycle. If out-of-period transactions are identified, the organization will ensure that these expenses are allocated to unrestricted general operating funds. Anticipated completion date: October 2026 Contact person responsible for corrective action: Harjeet Sidhu, Chief Financial Officer
In Finding 2026-002, the Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain wage authorization approvals for all employees. Management recognizes the importance of the f...
In Finding 2026-002, the Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain wage authorization approvals for all employees. Management recognizes the importance of the federal requirements regarding personnel cost and time and effort. In response to Finding 2026-002, procedures. will be established to ensure that wage authorizations are approved for all employees and that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle.
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discount for six sliding fee patients tested. In addition, ten patients received discounts without completed applications. Management recognizes the importance of complying with sliding fee guidelines a...
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discount for six sliding fee patients tested. In addition, ten patients received discounts without completed applications. 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 discounts will be reviewed on a monthly basis by a supervisor to ensure compliance with the sliding fee policy.
Finding 2026-004 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain lease agreements in tenant files and establish processes and procedures to ensure compliance with...
Finding 2026-004 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain lease agreements in tenant files and establish processes and procedures to ensure compliance with the provisions in the Regulatory Agreement. Anticipated Completion Date September 30, 2026
Finding 2026-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain the premises in reasonable condition for proper audit and subject to examination and inspection. ...
Finding 2026-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain the premises in reasonable condition for proper audit and subject to examination and inspection. Anticipated Completion Date September 30, 2026
Finding 2026-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action The Board of Directors will conduct board meetings as frequently as needed to allow them t...
Finding 2026-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action The Board of Directors will conduct board meetings as frequently as needed to allow them to fulfill their responsibilities and/or obtain counsel if meetings cannot be scheduled/held. Anticipated Completion Date September 30, 2026
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2026 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2026 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended February 28, 2026. Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Rental and Cooperative Housing (Section 221(d)(4)) Finding 2026-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will follow our policies and procedures to ensure accounting records are accurate and complete. Anticipated Completion Date September 30, 2026
SECTION 5 – CORRECTIVE ACTION PLAN Finding 2026 – 001: Restatement to Net Position Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets that were improperly recorded in prior years. Plan: The Authority will implement internal con...
SECTION 5 – CORRECTIVE ACTION PLAN Finding 2026 – 001: Restatement to Net Position Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets that were improperly recorded in prior years. Plan: The Authority will implement internal controls to properly record capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completion: Fiscal Year 2027 Name of Contact Person: Lisa Mittel, Assistant Director of Management Services Management Response: Management recognizes the finding and has implemented a tracking system to document historical capital assets, register adjustments, and record future acquisitions.
2026-002 – Deposits in excess of FDIC insured limits Corrective action planned: Appleway Court 202 will review the current deposit situation and related FDIC coverage and split cash deposits between multiple banks or work with our current bank to ensure that amounts in excess of FDIC limits are full...
2026-002 – Deposits in excess of FDIC insured limits Corrective action planned: Appleway Court 202 will review the current deposit situation and related FDIC coverage and split cash deposits between multiple banks or work with our current bank to ensure that amounts in excess of FDIC limits are fully insured and collateralized. Anticipated completion date: May 31, 2027 Contact person responsible for corrective action: Charles Wells, CFO
2026-005 Special Tests and Provisions Corrective action planned: In December 2025, responsibility for administration of the Sliding Fee Discount Program (SFDP) was transferred from the COO to the CFO/DFO. Several upgrades in tools used for determinations, reporting, and quality assurance were immedi...
2026-005 Special Tests and Provisions Corrective action planned: In December 2025, responsibility for administration of the Sliding Fee Discount Program (SFDP) was transferred from the COO to the CFO/DFO. Several upgrades in tools used for determinations, reporting, and quality assurance were immediately instituted. OMC review now includes electronic calculations of income, and several instances of documenting the SFDP appear on the application. Furthermore, each application package now includes a copy of the OMC Federal Poverty Level sliding scale with the determination clearly marked on the form. OMC’s SFDP Scales are also displayed in the lobby area and other visible areas at all OMC sites. Finally, the CFO/DFO performs a quarterly audit of all applications entered in that quarterly period. Each application is reviewed for completeness, and each participant’s account is reviewed for proper application of the SFDP. Any findings are corrected immediately and reported to the Quality Assurance committee so methods can be developed to prevent future errors. Anticipated completion date: 12/31/2025 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
2026-003 Period of Performance (repeat of finding 2025-003) Corrective action planned: The former CEO of OMC did not understand Generally Accepted Accounting Principles and, specifically, Accrual Accounting. He did not allow the Accounting Department to make accrual entries monthly. At the beginning...
2026-003 Period of Performance (repeat of finding 2025-003) Corrective action planned: The former CEO of OMC did not understand Generally Accepted Accounting Principles and, specifically, Accrual Accounting. He did not allow the Accounting Department to make accrual entries monthly. At the beginning of FY 2026 - 2027, the CFO/DFO required the accrual of payroll each month to accurately reflect the personnel expense of OMC. OMC accounting staff will utilize the Sage Impact® Accounting System to accrue other expenses that were incurred in the period but not yet paid, so that only cost for goods and/or services incurred within the approved budget period are reflected accurately in monthly financial reporting and costs are not allocated outside the budget period. The CFO/DFO has developed an accrual template so that utility bills that cross periods, such as one example in this report, are properly accounted for and allocated to the correct period. This will also be monitored by the external independent financial consultant and the CEO who is a degreed accountant. Anticipated completion date: 08/31/2026 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 th...
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 through August 26, 2029 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: AACHC implemented revised subrecipient monitoring procedures in October 2025 as part of its corrective action plan to address the prior-year finding. The revised procedures were applied to all active and new subrecipient agreements beginning October 2025. However, because certain subrecipient agreements had already concluded before the new procedures were implemented, AACHC did not retrospectively apply the monitoring process to those closed agreements. As a result, AACHC did not obtain and review financial statement audit or Single Audit reports for three subrecipients whose agreements ended prior to implementation of the revised procedures. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2027 Views of Responsible Officials and Corrective Action Plan: In October 2025, AACHC implemented revised subrecipient monitoring procedures in response to the prior-year audit finding. The exception identified in the current audit relates solely to three subrecipient agreements that had already concluded before the revised procedures were implemented and therefore could not be incorporated into the new monitoring process. Effective October 1, 2025, AACHC implemented enhanced procedures requiring evaluation of Single Audit applicability, collection and review of applicable audit reports, and follow-up on any findings. In addition, AACHC now requires subrecipients to submit audit documentation covering the entire period of performance under the agreement, ensuring that monitoring activities are completed even when a subrecipient agreement ends prior to the completion of the audit cycle. This corrective action addresses the circumstances that gave rise to the finding and provides assurance that all subrecipient agreements are subject to appropriate audit review and follow-up moving forward.
Finding 2026-003: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-006 Criteria: 24 CFR §982.405 states the PHA must conduct supervisory qualify control HQS inspections. Condition: The Authority performe...
Finding 2026-003: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-006 Criteria: 24 CFR §982.405 states the PHA must conduct supervisory qualify control HQS inspections. Condition: The Authority performed quality control inspections during the year; however, the Authority was not maintaining a log of inspections and had to search emails to find them. Further, the quality control inspections were not a random selection but selected by the original inspector. The Authority was not maintaining a log of all inspections for the quality control inspector to select from. Four of the 8 quality control inspections were done more than 90 days after the initial inspection. Cause: The Authority did not have procedures in place to randomly select inspections to perform quality control inspections on. Further, the Authority did not have a log of inspections and quality control inspections completed. Effect or Potential Effect: The Authority did not comply with the requirements of 24 CFR §982.405. Because inspections were not randomly selected, were not always performed within required timeframes, and were not adequately documented, the Authority did not have assurance that HQS inspections were being conducted consistently and in accordance with HUD requirements. Recommendation: The Authority should review the requirements of 24 CFR §982.405 and establish a system of where HQS inspections have a quality control sampling during each fiscal year. View of the Responsible Officials of the Auditee: The auditee's management agrees with the finding.
Finding 2026-002: Compliance, Inadequate Compliance Monitoring, Regulatory Oversight, and Governance Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2025-004 Criteria: Management is responsible for establishing and maintaining...
Finding 2026-002: Compliance, Inadequate Compliance Monitoring, Regulatory Oversight, and Governance Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2025-004 Criteria: Management is responsible for establishing and maintaining effective internal controls over compliance that provide reasonable assurance the Housing Choice Voucher Program is administered in accordance with Federal statutes, regulations, and HUD requirements. Effective controls should include adequate monitoring of compliance requirements, timely implementation of regulatory changes, maintenance of current policies and procedures, and oversight sufficient to compensate for staffing limitations. HUD program requirements and regulatory changes should be reviewed and incorporated into the Authority's Administrative Plan in a timely manner. Similar control expectations are reflected in HCV compliance guidance addressing policy maintenance, Board oversight, monitoring of regulatory changes, and compensating controls where segregation of duties is limited. Condition: The Authority operates only the Housing Choice Voucher Program and employs a single individual responsible for substantially all program administration and compliance responsibilities. Because staffing levels do not permit traditional segregation of duties, the Authority should have established compensating monitoring and oversight controls. However, our audit identified significant weaknesses in the Authority's internal control structure over compliance. Specifically, we noted: • Compliance responsibilities were concentrated in one individual without independent review or documented monitoring procedures. • The Administrative Plan had not been updated to incorporate applicable HOTMA requirements. • Board minutes indicated the Authority was relying upon HUD Notices H-2025-03 and H-2025-07 when evaluating HOTMA implementation. These notices do not apply to the Housing Choice Voucher Program and the Authority was not utilizing the correct guidance in HUD PIH Notices. • The Authority had not established procedures to identify, evaluate, and implement applicable HUD PIH notices and other regulatory updates affecting the Voucher program. • Audit testing identified deficiencies in multiple compliance areas, indicating that compliance monitoring controls were not operating effectively. The existence of compliance deficiencies across multiple program areas demonstrates that the Authority's controls were not reasonably designed or operating effectively to ensure compliance with Federal program requirements. Similar conditions have been identified in other HCV compliance control assessments, including lack of monitoring of regulatory changes, inadequate Board oversight, and insufficient compensating controls where staffing is limited. Cause: The Authority has not established an effective system of internal control over compliance. Management and the Board of Commissioners did not implement sufficient compensating controls to address the risks associated with a single-employee operating structure. In addition, procedures were not established to ensure that changes in HUD regulations, notices, and program requirements were identified, evaluated, and incorporated into Authority policies and operational practices on a timely basis. Effect: The lack of effective compliance oversight increases the likelihood that material noncompliance with Federal program requirements could occur and not be prevented, detected, or corrected timely. Failure to maintain current policies and implement regulatory changes increases the risk of noncompliance in areas including tenant eligibility, rent calculations, utility allowances, inspections, reporting, and other program requirements. The deficiencies identified during the audit demonstrate that the Authority's control environment does not provide reasonable assurance of compliance with Housing Choice Voucher Program requirements. Recommendation: We recommend the Authority: 1. Establish formal procedures for monitoring compliance with Housing Choice Voucher Program requirements. 2. Update the Administrative Plan to incorporate all applicable HOTMA requirements and other current HUD guidance. 3. Develop a process for reviewing HUD PIH notices, regulatory updates, and other program guidance as issued. 4. Implement documented supervisory or independent compliance reviews to compensate for the lack of segregation of duties. 5. Provide periodic compliance reports to the Board of Commissioners and document Board oversight of corrective actions. 6. Establish written procedures to ensure significant regulatory changes are timely evaluated, adopted, and implemented. Views of Responsible Officials The Authority agrees with the finding.
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
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval operated effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at ...
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval operated effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at both the beginning and end of the project are in the file. Staff has already set up either bi-weekly or monthly meetings (depending on project activity levels) to report on the status of ongoing projects. These meetings were intended to help staff keep current projects in line with the overall project budget (i.e. not obligating funds beyond what’s available). Using these same meetings to check project files for all necessary records will be an adjustment of negligible effort. In instances where there is a sizable gap between portions of a project (e.g. part of the project can’t be completed until spring) staff will consider closing out the completed portion of the project and completing a final inspection on the balance of the job at a later date. Contact person responsible for corrective action: Edwin Manninen, Matthew Wallace Anticipated Completion Date: Immediately
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.
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.
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.
Material Weakness: See Finding 2025-002. Recommendation: Management should establish a formal grant management policy defining roles, documentation standards, tracking procedures, report reconciliations, record retention, review and approval requirements, and periodic monitoring. The policy and asso...
Material Weakness: See Finding 2025-002. Recommendation: Management should establish a formal grant management policy defining roles, documentation standards, tracking procedures, report reconciliations, record retention, review and approval requirements, and periodic monitoring. The policy and associated procedures should consider all relevant requirements of Uniform Guidance, as well as specific requirements set forth in grant agreements and contracts. 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.
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