There is no disagreement with the audit finding. Action planned in response to finding: Management concurs with the finding. The Organization recognizes that documentation and reconciliation procedures supporting the Uniform Data System (UDS) submission were not sufficient to demonstrate the accurac...
There is no disagreement with the audit finding. Action planned in response to finding: Management concurs with the finding. The Organization recognizes that documentation and reconciliation procedures supporting the Uniform Data System (UDS) submission were not sufficient to demonstrate the accuracy and completeness of all reported data elements. During 2026, management will implement formal procedures requiring each UDS reporting element to be supported by documented source data, reconciled to underlying records, and independently reviewed prior to submission. These procedures will include a pre-submission review checklist and internal timeline so that all reconciliations and supporting documentation are completed and reviewed in advance of the UDS reporting deadline. Responsibility for preparation, review, and approval of UDS reporting will be formally assigned and documented. To strengthen this review, management plans to hire additional senior management personnel, including an Accounting Manager, to support the Accounting Department and oversee reconciliation of the UDS financial tables (Tables 8A, 9D, and 9E) to the general ledger and audited financial statements. In addition, management plans to hire a Director of Risk and Compliance, who will be responsible for overseeing the Organization's compliance with HRSA Health Center Program requirements, including the UDS reporting process. The Director of Risk and Compliance will perform an independent review of the completed UDS submission prior to certification, verifying that each reported data element is supported by documented source data and reconciliations, and will periodically monitor adherence to the procedures described in this response, with results reported to the Chief Executive Officer (CEO) and the Board of Directors. Any discrepancies identified before or after submission will be documented, investigated, and corrected in a timely manner, including through the HRSA UDS review and revision process where applicable. Management will also provide additional training to all staff involved in collecting, preparing, and reviewing UDS data, covering HRSA UDS reporting requirements, data definitions, and documentation standards. In addition, management will establish document retention procedures to ensure all supporting schedules, reconciliations, and reports are maintained in a centralized location and readily available for future review. New policies requiring timely account reconciliations and the retention of supporting records will be monitored and reviewed regularly by the Chief Financial Officer (CFO) to ensure they are consistently followed. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: June 30th, 2027