Corrective Action Plans

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2025-003 Material Weakness Internal Control – Special Tests / Prevailing wages C. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for obtaining certified payrolls as needed in conjunction with construction projects. D. Actions Taken or Planned: Management will requ...
2025-003 Material Weakness Internal Control – Special Tests / Prevailing wages C. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for obtaining certified payrolls as needed in conjunction with construction projects. D. Actions Taken or Planned: Management will request certified payrolls for any future construction contracts as required by federal regulation. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
2025-002 Material Weakness Internal Control / Noncompliance – Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current...
2025-002 Material Weakness Internal Control / Noncompliance – Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for reporting program personnel cost. B. Actions Taken or Planned: Management will continue to evaluate their controls with respect to current federal awards and requirements to insure accurate information captured and reported in accordance with the required timelines by implementing additional oversight. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
2025-001 Material Weakness Internal Control / Noncompliance – Eligibility A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under ...
2025-001 Material Weakness Internal Control / Noncompliance – Eligibility A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management implemented changes to the capturing and files maintained for documenting a participant’s eligibility for participation in program services. Management will continue to evaluate their controls with respect to current federal awards and requirements to ensure accurate information captured, reported and maintained. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design and implement controls to ensure that time and effort related to federal programs is appropriately documented a...
U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design and implement controls to ensure that time and effort related to federal programs is appropriately documented and retained in accordance with Uniform Guidance requirements, regardless of contract type. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New Management is continuing advocacy to recover missing documentation from previous payroll provider. New payroll provider maintains all records and archives. For those employees who work on federal grants, attestations of time spent on programs are being produced. Name(s) of the contact person(s) responsible for corrective action: Kate Mombourquette Planned completion date for corrective action plan: Completed 12/31/2025
The Stoneham Public Schools are under new fiscal management as of October 29, 2025. As part of this change, grants are being initiated with an information sheet to all grant managers which provides start and end dates for eligible expenditures, as well as MUNIS budget codes for directly expensing re...
The Stoneham Public Schools are under new fiscal management as of October 29, 2025. As part of this change, grants are being initiated with an information sheet to all grant managers which provides start and end dates for eligible expenditures, as well as MUNIS budget codes for directly expensing reasonable and allocable expenses to the grant via a requisition/purchase order/ AP process used throughout the district. The grant budget codes are established in direct coordination with the approved grant budget at the time of award, and will be updated if amendments are required. The finance office will also receive these grant information sheets, and provide a cross check of the eligibility and coding requirements as requisitions are processed. No expenses shall be allowed in advance of an approved purchase order.
Finding: 2025-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with condu...
Finding: 2025-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2026
Corrective Action Plan Eligibility Finding 2025-002 Roof Above will add signature lines to current client eligibility checklist, to include the name, signature and date for both the person preparing and the person reviewing tenant eligibility. Contact person responsible for corrective action: Katie ...
Corrective Action Plan Eligibility Finding 2025-002 Roof Above will add signature lines to current client eligibility checklist, to include the name, signature and date for both the person preparing and the person reviewing tenant eligibility. Contact person responsible for corrective action: Katie Church, Vice President of Scattered Site Housing Anticipated completion date: June 30, 2026
Corrective Action Plan Fiscal Year 2025 Finding Number: 2025-001 – Pell Grant Special Tests and Provisions – NSLDS Reporting The District acknowledges the findings related to NSLDS enrollment reporting and has conducted an internal review of processes, systems, and oversight structures contributing ...
Corrective Action Plan Fiscal Year 2025 Finding Number: 2025-001 – Pell Grant Special Tests and Provisions – NSLDS Reporting The District acknowledges the findings related to NSLDS enrollment reporting and has conducted an internal review of processes, systems, and oversight structures contributing to the finding. To ensure compliance with federal reporting requirements, the District will implement the following corrective actions: 1. Enhanced Review Procedures: The District will strengthen internal controls over enrollment reporting by implementing procedures to ensure all enrollment status changes are accurately recorded, reconciled between internal systems and third-party servicer reports, and submitted to NSLDS within required time frames. Additionally, The District is actively restructuring internal systems and workflows within the department to strengthen oversight, improve accuracy, and ensure timely reporting of enrollment status changes. 2. Training: The District recognizes that staff turnover and inconsistent training contributed to the finding. To address this, the District will implement a comprehensive training plan in partnership with the third-party servicer. 3. Monitoring Controls: The District will formally reestablish expectations with its third-party servicer to ensure all contracted services are implemented. Implementation Timeline: • Enhanced review procedures will be implemented immediately. • The District will implement an ongoing comprehensive training plan in partnership with third-party servicer. • Staff will meet with third-party servicer to re-establish expectations and to ensure compliance with federal reporting requirements before fiscal year-end. Responsible Party: Dr. Dywayne B. Hinds, Sr., Area Superintendent, Dr. Jakub Prokop, Director, PTC- Clearwater, and Dr. Jason Shedrick, Director, PTC-St. Petersburg Anticipated Completion Date: June 30, 2026 Dywayne B. Hinds, Sr., Ed.D. Area Superintendent, Area 3
OLD TOWNE SQUARE, INC. CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 AND 2024 Old Towne Square, Inc 609 SW F Avenue Lawton, OK 73501 Telephone: (580) 353-7392 Fax: (580) 353-6111 Corrective Action Plan Finding: 2025-001-Lack of Adequate Quality Control Regarding Tenant Procedures- Eligibility Cond...
OLD TOWNE SQUARE, INC. CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 AND 2024 Old Towne Square, Inc 609 SW F Avenue Lawton, OK 73501 Telephone: (580) 353-7392 Fax: (580) 353-6111 Corrective Action Plan Finding: 2025-001-Lack of Adequate Quality Control Regarding Tenant Procedures- Eligibility Condition: The quality of supervision over tenant file functions, such as calculating tenant rent and Housing Assistance Payments should be timely and sufficient to find errors in calculations or mis-application or mis-understanding of procedures. Corrective Action Planned: I am Rita Love, Executive Director. We will comply with the auditor’s recommendation. Person responsible for corrective action: Anna Richman, Executive Director Telephone: (580) 353-7392 Old Towne Square, Inc. Fax: (580) 353-6111 609 SW F Avenue Lawton, OK 73501 Anticipated Completion Date: June 30, 2026
Finding 2025-004 Finding Subject: Title I Grants to Local Educational Agencies – Special Tests and Provisions – Participation of Private School Children Summary of Finding: The School Corporation did not provide supporting documentation for the amounts disbursed for Participation of Private School C...
Finding 2025-004 Finding Subject: Title I Grants to Local Educational Agencies – Special Tests and Provisions – Participation of Private School Children Summary of Finding: The School Corporation did not provide supporting documentation for the amounts disbursed for Participation of Private School Children. No time sheets or logs were provided to support the hours paid to employees for working with the Private School Children. Contact Person Responsible for Corrective Action: Randi Libby, Chief Operating Officer Contact Phone Number and Email Address: (260)431-2030, rlibby@sacs.k12.in.us Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will implement procedures to ensure consistent documentation supporting Title I services provided to non-public school students. All Title I staff providing services to non-public schools will be required to submit consistent, detailed timesheets documenting hours and/or days worked by non-public school, activity, and grant year. Timesheets will be completed, reviewed, and approved prior to payroll processing. The Payroll Manager will not process payroll for Title I non-public services unless the required timesheets are submitted and approved. Approved timesheets will be retained in the payroll files and organized by payroll dates, and will be made available for audit review. Anticipated Completion Date: July 1, 2026 _________________________ _Randi Libby (Signature) _______Chief Operating Officer __ (Title) __________January 7, 2026__________ (Date)
Name of Auditee: East Ramapo Central School District Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2025 CAP Prepared by: Eric Stark, Assistant Superintendent for Business Phone: 845-577-6000 (A) Current Findings on the Schedule of Findings and Questioned...
Name of Auditee: East Ramapo Central School District Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2025 CAP Prepared by: Eric Stark, Assistant Superintendent for Business Phone: 845-577-6000 (A) Current Findings on the Schedule of Findings and Questioned Costs (4) Audit Finding 2025-004 (a) Comments on the Finding and Recommendation: The District agrees with the finding. The District also agrees with the recommendation. See below for actions taken. (b) Actions Taken: Management will not approve expenditures or sign checks for cash disbursements that have not been approved by the claims auditor. (c) Anticipated Completion Date: Management anticipates this finding will be resolved by June 30, 2026.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of Schuylkill - Home Investm...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: HOME Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Agencies: City of Philadelphia, Redevelopment Authority: Venango – Loan Thompson Street – Loan County of Schuylkill - Home Investment Partnerships and Housing Trust Funds Programs: Fountain Springs - Loan Mayor and City of Baltimore: Baltimore Housing - Park Heights Women and Children - Loan Type of Finding: - Material Weakness in Internal Control over Compliance - Other Matters Condition: As part of the eligibility requirement for the HOME Investment Partnership program, we are required to review files of client residents who were provided residential drug and alcohol treatment services at the Organization’s locations in Venango (Re-Entry), Fountain Springs, Thompson Street, and Park Heights Women and Children. We sampled a total of 40 resident clients at these four locations covered by HOME loans and requested documentation within client resident files, including proof of residency, proof of income (low income or homeless). Of 40 resident client files reviewed, management could not provide proof of income or residency status for 16 clients, or policies and procedures manuals for 22 clients. Recommendation: We recommend that management adopt and implement formal policies and procedures to ensure compliance with HOME eligibility requirements. Such policies and procedures should include clear communication of compliance requirements between staff and locations, standardized documentation and processes for determining and verifying income eligibility during intake, and procedures for the redetermination of income eligibility for residential clients residing at a location for more than one year. Repeat Finding: 2024-001 Explanation of Disagreement with Audit Finding Management acknowledges the finding and continues to strengthen internal controls related to HOME program compliance, including eligibility documentation and file retention practices across all residential program locations. Management agrees that consistent documentation of eligibility, including proof of income and residency status (as applicable under HOME requirements), is critical. We are currently reviewing and enhancing intake procedures, documentation standards, and internal monitoring processes to ensure all required eligibility documentation is properly obtained, maintained, and uniformly applied across all locations. Action taken in response to finding: In response to the recommendation, management will develop and implement formalized policies and procedures to strengthen compliance with HOME requirements. These will include standardized guidance for eligibility determination at intake, clear documentation requirements across all sites, and procedures for ongoing eligibility review for clients residing in programs beyond one year. Name of the contact person responsible for corrective action: Dr. Deja Gilbert, PhD, MDA, FACHE, LPC, LMHC, President and CEO dgilbert@gaudenzia.org Planned completion date for corrective action plan: June 30, 2026
Recommendation: We recommend the College evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are returned within the required timeframe. Explanation of disagreement with audit finding: There is no disagreeme...
Recommendation: We recommend the College evaluate its procedures and review policies in overseeing student credit balances to ensure that any credit balances as a result of Title IV aid are returned within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The institution will conduct a comprehensive policy review related to student accounts and financial aid disbursements. The Student Accounts team will receive retraining, including additional Financial Aid–specific training focused on federal guidelines and compliance requirements. Cross training will be implemented within the Student Accounts team to prevent delays and ensure continuity of operations when staff are on leave. Ongoing communication protocols will also be reinforced between Student Accounts and the outsourced financial aid staffing team (Financial Aid Services (FAS)) regarding disbursement timing to promote coordination and timeliness. Name(s) of the contact person(s) responsible for corrective action: Scott Crawford, Director of Accounting and Melissa Ogelvie, Bursar Planned complet ion date for corrective action plan: July 1, 2027 – While we anticipate improvement in these processes throughout the training process, completion of these corrective actions will be complete by this date. This timeline accounts for the identification, scheduling, and completion of appropriate training opportunities, including potential external training or professional development programs that may require advance enrollment and availability.
Finding Number: 2025-006 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on com...
Finding Number: 2025-006 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on completion of the FNS-46 S-EBT and FNS-388 S-EBT reports. All noted reports have been revised, if necessary, reviewed, and certified. Staff have been trained on the updated procedures. Anticipated Completion Date: Complete Contact Person: Name: Renee Ikard Title: Chief Financial Officer Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8985 Email Address: Renee.Ikard@dhs.arkansas.gov
Finding Number: 2025-003 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance that r...
Finding Number: 2025-003 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance that requires Summer EBT funds to be drawn down after expenditures are made. All funds expunged from EBT cards are in the process of being returned to FNS. Anticipated Completion Date: 3/31/2026 Contact Person: Name: Renee Ikard Title: Chief Financial Officer Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8985 Email Address: Renee.Ikard@dhs.arkansas.gov
240 Day Outstanding Payments Recommendation: We recommend the District implement a review process for outstanding student payments to ensure any that include Title IV funds are refunded to the U.S. Department of Education within 240 days. Explanation of disagreement with audit finding: There is no d...
240 Day Outstanding Payments Recommendation: We recommend the District implement a review process for outstanding student payments to ensure any that include Title IV funds are refunded to the U.S. Department of Education within 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: The Financial Aid Coordinator will create and maintain a SharePoint spreadsheet to effectively track and monitor outstanding student payments. The Workforce Finance Department will support the setup and ensure the spreadsheet aligns with established financial monitoring practices. Responsible party: Financial Aid Coordinator and Workforce Finance Department Planned completion date for corrective action plan: April 30, 2026 Plan to monitor completion of corrective action plan: The Financial Aid Coordinator and Workforce Finance Department will conduct monthly reviews to ensure the spreadsheet is updated, accurate, and used consistently for monitoring outstanding payments.
Special Tests and Provisions Recommendation: It is recommended that the District strengthen its internal controls over the R2T4 calculation process by implementing a secondary review or quality-assurance check of scheduled clock hours prior to finalizing R2T4 calculations. Staff should receive targe...
Special Tests and Provisions Recommendation: It is recommended that the District strengthen its internal controls over the R2T4 calculation process by implementing a secondary review or quality-assurance check of scheduled clock hours prior to finalizing R2T4 calculations. Staff should receive targeted training on the requirements of 34 CFR § 668.22, particularly regarding the use of scheduled hours in determining earned aid and post-withdrawal disbursement eligibility. Additionally, standardized calculation worksheets or system-generated hour reports should be utilized to reduce reliance on manual entry and minimize the risk of human error. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: Financial Aid Coordinators from both technical colleges will collaborate to review and audit each other's RT24 calculations to ensure accuracy, accountability, and compliance with regulatory requirements. Responsible party: Financial Aid Coordinator Planned completion date for corrective action plan: April 1, 2026 Plan to monitor completion of corrective action plan: Monthly meetings with the Workforce Finance Department will be held to review RT24 calculations, address discrepancies, and confirm ongoing compliance.
Common Origination & Disbursement Reporting Recommendation: We recommend the District evaluate its procedures and policies around reporting Pell disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disa...
Common Origination & Disbursement Reporting Recommendation: We recommend the District evaluate its procedures and policies around reporting Pell disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: Financial Aid Coordinators will monitor weekly to ensure matching of both systems. Responsible party: Financial Aid Coordinator and Administration Planned completion date for corrective action plan: April 1, 2026 Plan to monitor completion of corrective action plan: • The Financial Aid Coordinator will perform weekly reviews to confirm system alignment. • Administration will conduct quarterly oversight to ensure continued compliance and proper documentation.
Finding 2025-002 Material Weakness in Internal Control Over Special Tests and Provisions Compliance Requirements Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of He...
Finding 2025-002 Material Weakness in Internal Control Over Special Tests and Provisions Compliance Requirements Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2025 Criteria FFHC is responsible for keeping adequate supporting documentation of the calculation of patient service fees for those patients who qualify for discounted fees based on family size and household income. FFHC is also required to apply discounted fees accurately based on an approved sliding fee scale that meets federal compliance requirements. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2025 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2026 to remediate the finding and address the cause of the finding. •The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. •FFHC will enforce its current policy and related internal control procedures to ensure that supporting documentation of family size and household income is maintained for all patients that receive discounted patient service fees in relation to the Health Centers Program and Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program. •FFHC will enforce its current policy and related internal control procedures to ensure that discounted patient service fees are properly calculated and charged based on the applicable approved sliding fee scale. The target date for full implementation of these corrective actions is June 30, 2026. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 800 East 55th Street, Chicago, IL 60615.
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding 2025-001 Material Weakness in Internal Control Over Reporting Compliance Requirements Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Age...
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding 2025-001 Material Weakness in Internal Control Over Reporting Compliance Requirements Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2025 Criteria FFHC is responsible for preparing and submitting its annual Universal Report and Federal Financial Reports in a timely manner. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2025 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2026 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Finance Manager, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • To ensure compliance with timely submission of financial reports (FFR), Friend Health will implement a structured timeline that aligns with all regulatory deadlines and includes internal checkpoints to monitor progress. • The Organization has implemented a new Grants (Project) tracking module to better help with grants and contracts reporting and compliance. This module will track all deadline dates for all of the grants, including deadlines for submitting FFR’s. All grant-related year-end audit procedures have been transitioned to the Finance Manager who has experience with financial audits and compliance and reporting for City, State, and Federal grants. •The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the Federal Financial Reports. The target date for full implementation of these corrective actions is June 30, 2026. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 800 East 55th Street, Chicago, IL 60615.
FINDING 2025-002 USDA LOAN COVENANTS COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and EHR system in May 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearin...
FINDING 2025-002 USDA LOAN COVENANTS COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and EHR system in May 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the Hospital offline from processing claims. These two events had a negative and material impact on the Hospital’s cash collections over the last two years resulting in the Hospital not having the required 90 days of cash on hand. The Hospital did receive a waiver from the USDA regarding not meeting this loan covenant for fiscal year 2025. Views of responsible officials and planned corrective actions The Hospital has made several changes to its system since the initial implementation and has contracted with a third party vendor to make improvements in its billing and collection processes. These changes are expected to result in cash collection improvements. Additionally, the Centers for Medicare and Medicaid Services (CMS) approved the State of Nebraska’s preprint and provider assessment waiver that governs Nebraska’s Medicaid Directed Payment Program (Program). CMS’ approval of the Program is for the period July 1, 2024 through December 31, 2024 and January 1, 2025 to December 31, 2025 only, with future years subject to an annual approval by CMS. These additional funds are also expected to significantly improve the Hospital’s days of cash on hand by the end of fiscal year 2026. Hospital management notified its USDA representatives and received a waiver from the 90 days of cash on hand for the period ended June 30, 2025. Anticipated completion date Ongoing
2025-002 Reporting Recommendation: We recommend the City review and update internal controls to ensure that the City submits accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Based on t...
2025-002 Reporting Recommendation: We recommend the City review and update internal controls to ensure that the City submits accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Based on the City’s review, the omission of this specific requirement from the bid documentation and subsequent reporting process appears to have been inadvertent and the result of the circumstances described above, rather than the result of intentional noncompliance. The City has since reviewed its procedures and is implementing additional internal review measures to help ensure that all applicable grant requirements are incorporated into future procurement and reporting processes. Name(s) of the contact person(s) responsible for corrective action: Alana Mantilla, Michael Lee, and Rafael Fajardo Planned completion date for corrective action plan: June 2026
Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Materia...
Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees and acknowledges the findings related to the application and review of sliding fee discounts under the Self-Pay Discount Program. The Department recognizes the importance of consistent application of sliding fee discount schedules and proper documentation of review processes to ensure full compliance with federal requirements. The Department is committed to maintaining strong internal controls and ensuring adherence to all applicable policies, procedures, and regulatory standards governing the Sliding Fee Discount Program. View of Responsible Officials and Corrective Action: HCA Management agrees with the finding and will implement corrective actions to strengthen internal controls and ensure consistent application of the sliding fee discount program. The following actions will be taken: • Reinforcement of Policies and Procedures: Re-educate all applicable staff on existing sliding fee discount program policies, including proper calculation and application of discounts. First re-education session was held on February 4, 2026. • Standardization of Workflow: Update and implement standardized workflows and job aids within the registration and billing processes to ensure discounts are applied accurately and consistently. Standardized workflows completed on February 2, 2026. • Enhanced Review and Oversight: Establish a formalized secondary review process for sliding fee discount determinations, including required documentation and supervisory sign-off. Supervisor sign off on sliding fee applications by April 1, 2026. • Ongoing Training: Incorporate sliding fee discount program requirements into onboarding and annual refresher training for relevant staff beginning April 1, 2026. • Audit and Monitoring: Conduct monthly internal audits of sliding fee discount applications to monitor compliance and identify any trends or gap by May 1, 2026. These corrective actions are designed to ensure compliance with federal requirements, improve consistency in application, and strengthen overall internal controls. Name of Responsible Persons: Octavius Gonzaga, Ambulatory Care CFO – Establishes sliding fee discount program policy, procedures, and fee schedules. Erika Herincx, Ambulatory Care Revenue Cycle Manager – Responsible for the oversight of the training program and ensures the listed activities in the Corrective Action Plan are executed. Implementation Date: February 4 - March 30, 2026 – Training of front-end staff and clinic management. April 1, 2026 – Implementation of supervisor sign off for each sliding fee application. April 1, 2026 – Re-Training of Medical Billing Specialists on adjustments. May 1, 2026 – Monthly sampling of encounters December 1, 2026 – Year-to-date report and internal audit
The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete tim...
The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete timely vouchers will occur. This new process will enable the fiscal employees responsible for vouchering to complete their functions in a timely manner.
Name of Contact Person: Kristy Christenberry, Interim Chief Finance Officer Corrective Action Plan: The Board of Education will implement controls and procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. Proposed Completion Date:...
Name of Contact Person: Kristy Christenberry, Interim Chief Finance Officer Corrective Action Plan: The Board of Education will implement controls and procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. Proposed Completion Date: Immediately
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