Corrective Action Plans

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Description: The SEFA schedule included unallowable costs. Planned Corrective ActionL CGS will revise its SEFA preparation procedures to ensure that only allowable and properly reimbursable expenditures on federal awards are reported. Additional training will be scheduled for those responsible sta...
Description: The SEFA schedule included unallowable costs. Planned Corrective ActionL CGS will revise its SEFA preparation procedures to ensure that only allowable and properly reimbursable expenditures on federal awards are reported. Additional training will be scheduled for those responsible staff members to ensure that this error does not happen in the future. Anticipated Completion Date: October 1, 2025 Responsible Person: Keith Peregonov, VP for Finance, Human Resources and Operations
The City will continue to work with all agencies receiving HOPWA to complete their annual CAPER correctly and in a timely manner. This emphasis will be reiterated throughout the awarding process and will be subject to regular status updates to ensure compliance and accuracy. Further, the City will w...
The City will continue to work with all agencies receiving HOPWA to complete their annual CAPER correctly and in a timely manner. This emphasis will be reiterated throughout the awarding process and will be subject to regular status updates to ensure compliance and accuracy. Further, the City will work with HUD to establish a correct methodology in reporting consistency with IDIS.
Unaccompanied Children Program Assistance Listing No. 93.676 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respo...
Unaccompanied Children Program Assistance Listing No. 93.676 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review all timesheet approvals are completed monthly. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: Complete and ongoing
2004-002: Controls over Allowable Costs, etc. St. Jude’s Ranch for Children (the parent entity of HSB Holding Company) acknowledges that weaknesses in the financial oversight process contributed to this finding. Specifically, limited knowledge of Generally Accepted Accounting Principles (GAAP) and ...
2004-002: Controls over Allowable Costs, etc. St. Jude’s Ranch for Children (the parent entity of HSB Holding Company) acknowledges that weaknesses in the financial oversight process contributed to this finding. Specifically, limited knowledge of Generally Accepted Accounting Principles (GAAP) and federal cost principles by key financial personnel led to misclassification of costs and errors in reimbursement requests in a new type of grant unfamiliar to the accounting team. In response, the organization is restructuring its finance department to ensure that individuals with appropriate qualifications and experience in nonprofit GAAP and federal grant compliance are responsible for reviewing accounting records and reimbursement requests. This includes a new Chief Financial Officer with demonstrated experience in federal grant accounting and compliance and a dedicated grants manager to prepare all reimbursement submissions under the oversight of the CFO.
Identifying Number: 2024-007 Corrective Actions Taken or Planned: Finding: 2024-007 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. This gr...
Identifying Number: 2024-007 Corrective Actions Taken or Planned: Finding: 2024-007 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. This grant has ended as of 6/30/25. In the future if we have fiscal agency services, we will ensure the that the program is being properly reviewed and administered.
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditu...
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditures charged to grant programs. To address this finding, Tuerk House is taking the following corrective actions: ·Implementing a formal time and effort certification process that requires employees to certify actual time worked on federal grant activities on a regular basis, rather than relying on budgeted allocations. ·Developing a standardized cost allocation methodology that aligns with actual grant activity and is supported by verifiable documentation. ·Requiring that all expenditures charged to federal awards be supported by complete and accurate source documentation, including vendor invoices, timesheets, and approvals. ·Establishing a document retention policy consistent with 2 CFR § 200.334 to ensure all supporting records are retained for the required period and readily accessible for audit or review. Training sessions for program and finance staff will be conducted to ensure consistent understanding and application of these updated policies and procedures. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
View Audit 361681 Questioned Costs: $1
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Scott Wagner Contact Phone Number: 260-248-3121 Ext 5 swagner@whitleygov.com Views of Responsible Official: We concur with the finding. Descrip...
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Scott Wagner Contact Phone Number: 260-248-3121 Ext 5 swagner@whitleygov.com Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Whitley County Health Department has developed and implemented a policy that will establish and maintain effective internal control for invoices for State and Federal Grants received by the Department. The Director of the department will review all compiled data and sign the invoice along with the employee who compiled the invoice data. In cases where the Director is the employee compiling the data, the office administrator will also sign the invoice to verify the data is correct. Anticipated Completion Date: Immediately
Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant managem...
Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant management procedures have been revised to verify that services are received and costs incurred within the authorized period of performance in accordance with 2 CFR § 200.403 before the costs are charged to a federal award. Staff involved in grant management will receive targeted training on 2 CFR requirements related to period-of-performance compliance and allowable cost timing. Anticipated Completion Date: September 30, 2025
View Audit 361417 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance wi...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance with regard to the period of performance requirements.
View Audit 361368 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Gro...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Group will reconcile budgeted and actual fringe benefit costs regularly to ensure continued compliance.
View Audit 361368 Questioned Costs: $1
Finding 569813 (2024-037)
Significant Deficiency 2024
Finding: 2024-037 - A review of 16 FY 24 Disaster Grants program subrecipients’ obligating award documents found seven did not include all federally required information and one was also missing a completed assurances and agreement form. Questioned Costs: None Assistance Listing Number: 97.036 As...
Finding: 2024-037 - A review of 16 FY 24 Disaster Grants program subrecipients’ obligating award documents found seven did not include all federally required information and one was also missing a completed assurances and agreement form. Questioned Costs: None Assistance Listing Number: 97.036 Assistance Listing Title: Disaster Grants Public Assistance (Presidentially Declared Disasters) Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DMVA concurs with the finding. Corrective Action (corrective action planned): OAD, Assurance, and Agreement Forms: The Finance Officer in coordination with the Homeland Security Director will conduct a thorough review of the OAD, assurance, and agreement forms to comply with 2 CFR 200.332. Necessary updates to the pertinent forms will be made to reflect federal requirements and clearly identify the funding is a subaward to the subreceipient. Revision of Internal Procedures: The Finance Officer will revise and document internal procedures to ensure that: • Employees and contract support consistently validate the information contained in sam.gov against data provided by subrecipients • When applicable Homeland Security employees will review, validate, and certify work completed by a contractor prior to the issuance of a subaward Completion Date (list anticipated completion date): October 31, 2025 Agency Contact (name of person responsible for corrective action): Bryan Fisher
Finding 569780 (2024-083)
Significant Deficiency 2024
Finding: 2024-083 - One of 40 sampled transactions were coded incorrectly to the wrong grant. Questioned Costs: None Assistance Listing Number: 47.076 Assistance Listing Title: RDC Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, br...
Finding: 2024-083 - One of 40 sampled transactions were coded incorrectly to the wrong grant. Questioned Costs: None Assistance Listing Number: 47.076 Assistance Listing Title: RDC Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): There is no disagreement with the audit finding. Corrective Action (corrective action planned): The expenditure with issue was charged to a ‘Closed’ grant and UAF Office of Grants & Contracts Administration (OGCA) was not aware of this until it showed up on the aged receivable report so it was not corrected in time before year-end. OGCA will develop a plan to detect and correct these inappropriate expenditures charged on closed grants timely. Completion Date (list anticipated completion date): June 2025 Agency Contact (name of person responsible for corrective action): Michelle Bunch, Office of Grants and Contracts Associate Director, 907-474-6173
Finding 569769 (2024-035)
Significant Deficiency 2024
Finding: 2024-035 -Six of seven award extensions for the NGMOMP program were untimely. Additionally, one award was not closed timely. Questioned Costs: None Assistance Listing Number: 12.401 Assistance Listing Title: NGMOMP Views of Responsible Officials (state whether your agency agrees or ...
Finding: 2024-035 -Six of seven award extensions for the NGMOMP program were untimely. Additionally, one award was not closed timely. Questioned Costs: None Assistance Listing Number: 12.401 Assistance Listing Title: NGMOMP Views of Responsible Officials (state whether your agency agrees or disagrees with the finding if you disagree, briefly explain why): DMVA concurs with the finding. Corrective Action (corrective action planned): Administrative Services has consistently provided notification and set clear deadlines to the Federal and State Program Managers of an expiring award under the Cooperative Agreement (CA). This notification has included a financial report detailing posted expenses and open obligations and when applicable, a copy of the most resent approved extension for reference. Due to inconsistent and untimely responses, the Finance officer in conjunction with the Administrative Services Director will update and strengthen written procedures, elevating responsibility for follow-up when responses are not received to ensure timely submission of extension requests and award closeouts following 2 CFR 200.303(a), 2 CFR 200.308(e), and 2 CFR 200.344. Updated documented procedures and training will be provided to the components under the CA. Completion Date (list anticipated completion date): 06/30/2025 Agency Contact (name of person responsible for corrective action): Bob Ernisse Pamela Wiederspohn
Finding 2024-002 – Activities Allowed/Unallowed, Costs Principles and Period of Performance (Internal Controls Over Compliance) (Repeat Finding 2023-001) Condition: During our review of the Coalition’s disbursements related to the Title V major program, we examined 68 transactions for internal cont...
Finding 2024-002 – Activities Allowed/Unallowed, Costs Principles and Period of Performance (Internal Controls Over Compliance) (Repeat Finding 2023-001) Condition: During our review of the Coalition’s disbursements related to the Title V major program, we examined 68 transactions for internal controls over compliance. 7 of the 68 transactions examined did not contain sufficient evidence that a review and approval process was completed prior to payment being processed. Corrective Action Plan: In response to the finding regarding insufficient internal controls over compliance for disbursements related to the Title V major program, the Nebraska Urban Indian Health Coalition (NUIHC) has previously taken several corrective actions to strengthen compliance, including: 1. Review and Revision of Policies and Procedures: NUIHC conducted a comprehensive review of internal control policies and procedures related to disbursements. Updates were made to ensure alignment with 2 CFR §200.313(a), and clear guidelines for review and approval processes were established. 2. Staff Training and Education: Training was provided to procurement and finance staff to ensure understanding of the revised procedures and federal compliance requirements, emphasizing the importance of proper approvals prior to disbursement. 3. Implementation of Standardized Approval Controls: A formal approval process and checklist system were implemented to ensure all disbursements are reviewed and approved by designated authorities before payment, with documentation retained for compliance. 4. Ongoing Monitoring and Internal Reviews: NUIHC began conducting quarterly internal compliance checks to verify adherence to updated procedures. Update and Continuation Plan: While these corrective actions were successfully implemented, the retirement of the former CEO temporarily stalled consistent oversight and reinforcement of these procedures. With new leadership in place, NUIHC is recommitting to the continued execution and monitoring of these corrective actions. Refresher training will be incorporated into ongoing professional development and onboarding for new staff, and quarterly internal audits will resume as scheduled. Timeline for Implementation: Corrective actions were initially implemented in 2024, and reinforcement activities—including staff refreshers and compliance monitoring—will continue a rolling basis starting July 2025. Responsible Party: Chief Financial Officer, Carlett Gregory Anticipated Completion Date: Ongoing; reinforcement begins July 2025
Finding Reference Number: 2024-001 Description of Finding: Expenditures totaling $273,298 were incorrectly charged to the 93.464 program for a fiscal year in which the costs were not actually incurred. This misclassification resulted from recording expenses based on the purchase order date (Septemb...
Finding Reference Number: 2024-001 Description of Finding: Expenditures totaling $273,298 were incorrectly charged to the 93.464 program for a fiscal year in which the costs were not actually incurred. This misclassification resulted from recording expenses based on the purchase order date (September 30) rather than the actual service date, leading to overbilling for the grant year. Statement of Concurrence or Nonconcurrence: We concur with the audit finding regarding the misclassification of expenditures totaling $273,298 to the 93.464 program after the fiscal year-end. We acknowledge that these costs were recorded in the incorrect accounting period, resulting in an overstatement of grant expenditures for the fiscal year. Corrective Action: 1. Policy Update: CFILC will revise expense recognition policies to require that costs be recorded in the period matching the actual service date. 2. Year-End Review Process: CFILC will implement a formal review process at fiscal year-end to confirm expenses are attributed to the correct fiscal year. 3. Staff Training: CFILC will provide training for financial reporting and grant billing staff on the expense recognition policy and year-end review process. 4. Monitoring & Compliance: CFILC will establish periodic internal audits or reviews to ensure ongoing compliance with the updated procedures. 5. Finance Committee Oversight: Executive Director will report to the Finance Committee on the status of this corrective action plan by the completion date of December 31, 2025. Name of Contact Person: Kathrine Crowley, Acting Executive Director, kathrine@cfilc.org, (916) 232-1985 Projected Completion Date: December 31, 2025
2. Finding 2024-002 Section 1A of the grant agreement requires that the Credit Union expend its CDFI ERP Award in eligible activities including providing financial products in low-or moderate-income majority minority census tracts that are also ERP-Eligible geographies. a. Action(s) Taken or Planned...
2. Finding 2024-002 Section 1A of the grant agreement requires that the Credit Union expend its CDFI ERP Award in eligible activities including providing financial products in low-or moderate-income majority minority census tracts that are also ERP-Eligible geographies. a. Action(s) Taken or Planned on the Finding Management agrees with the finding and has established procedures to identify eligible loans deployed in the eligible ERP-Eligible geographies. These loans will be reconciled to the underlying loan servicing systems. b. Implementation Date: Procedures were developed and implemented in June 2025.
Finding 569028 (2024-002)
Significant Deficiency 2024
Condition: The county did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action Plan: The county f ill adopt needed policies per Uniform Guidance Responsible Official: Austin Hazelti,re, County Coordinator Expected Date of Completion: Dec ...
Condition: The county did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action Plan: The county f ill adopt needed policies per Uniform Guidance Responsible Official: Austin Hazelti,re, County Coordinator Expected Date of Completion: Dec mber 31, 2025
Finding Number: 2024-001 Condition: The City lacked adequate controls to verify that expenditures charged to the grant were incurred within the proper period of performance. Transactions were processed without sufficient review or procedures around the period of performance, resulting in expenditur...
Finding Number: 2024-001 Condition: The City lacked adequate controls to verify that expenditures charged to the grant were incurred within the proper period of performance. Transactions were processed without sufficient review or procedures around the period of performance, resulting in expenditures being charged from outside the allowable timeframe. Planned Corrective Action: The City has worked with the State to identify expenses outside the period of performance. The City has sent the money back to the State that was before the performance start date. All balances are properly stated as of November 30. 2024. Contact person responsible for corrective action: Connie Kumpula Anticipated Completion Date: 5/23/2025
Finding 567881 (2024-056)
Significant Deficiency 2024
Finding 2024-056 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - EM Grants Manager Security Management and Access Controls Management Views MSP agrees with the finding. MSP implemented the EM Grants Manager system in November 2023 and did not fully establish pr...
Finding 2024-056 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - EM Grants Manager Security Management and Access Controls Management Views MSP agrees with the finding. MSP implemented the EM Grants Manager system in November 2023 and did not fully establish procedures for maintaining documentation of user access forms, reviewing privileged access, and disabling inactive users due to the number of current disasters and limited staff. Planned Corrective Action For part a., MSP implemented an access approval process in November 2023 to maintain documentation of access request forms within the EM Grants Manager system. For parts b. and c., MSP will create procedures to help ensure the timely completion of privileged user reviews and inactive user deactivation. MSP will perform the required user reviews and deactivate applicable accounts by September 30, 2025. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Penny Burger, MSP
Finding 567845 (2024-049)
Significant Deficiency 2024
Finding 2024-049 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. Planned Corrective Action The LEO Office of Global Michigan (OGM) will improve established...
Finding 2024-049 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. Planned Corrective Action The LEO Office of Global Michigan (OGM) will improve established procedures and tracking logs to help ensure compliance with SOM Technical Standard 1340.00.020.01 (Access Control Standard). Specifically, LEO OGM will review user access semiannually for privileged accounts and annually for all other accounts. Also, LEO-IC is in the process of establishing a compliance team that will perform validation of the ongoing reviews. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Ben Cabinaw, LEO Allen Williams, LEO
Finding 567696 (2024-025)
Significant Deficiency 2024
Finding 2024-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action During fiscal year 2024, MDHHS improved the payment review process prior to manual input into the Medic...
Finding 2024-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action During fiscal year 2024, MDHHS improved the payment review process prior to manual input into the Medical Services Administration Manual Payment System (MSAPay) to help ensure there are no improper payments, as demonstrated by no improper payments identified for fiscal year 2024. MDHHS will develop and implement a post payment review process for the final respite payments that were entered into MSAPay during December 2024 and anticipates completion by September 30, 2025. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Crystal Kline, MDHHS Jessica Bowen, MDHHS Elaina Brown, MDHHS
Finding 567695 (2024-024)
Significant Deficiency 2024
Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 20...
Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 2024 to comply with overall EGLE guidance that all reimbursement requests should be reviewed by a program representative and financial representative to ensure payments are made for activities authorized by the grant agreement. However, WRD had not fully completed the retroactive review of payments for fiscal year 2024. This has since been corrected and all retroactive reviews to ensure compliance with program technical specifications were completed as of May 1, 2025. Anticipated Completion Date Completed Responsible Individual(s) Phil Argiroff, EGLE Amy Hicks, EGLE
Finding 567694 (2024-023)
Significant Deficiency 2024
Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure ...
Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure that Public Transportation Management System (PTMS) user access is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process which will include obtaining, verifying, and documenting the written approval for all identified users by the designated System Security Administrators. Access will be modified/removed, as appropriate, based on responses or removed for non-responders prior to the end of each six-month period for privileged users and each fiscal year for all other users. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Sandy Lovell, MDOT Gina Huhn, MDOT Jean Ruestman, MDOT Kyle Nelson, MDOT Andy Esch, MDOT
Finding 567678 (2024-021)
Significant Deficiency 2024
Finding 2024-021 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Extension Procedures Management Views DMVA agrees with the finding. Planned Corrective Action DMVA will set annual recurring calendar appointments to review program activities with the program managers...
Finding 2024-021 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Extension Procedures Management Views DMVA agrees with the finding. Planned Corrective Action DMVA will set annual recurring calendar appointments to review program activities with the program managers one month before the end of the period of performance to ensure a joint understanding of extension requirements, allowing sufficient time to prepare and submit period of performance extension requests timely, if needed. Anticipated Completion Date September 1, 2025 Responsible Individual(s) Rachelle Breeden, DMVA
Finding 567386 (2024-002)
Material Weakness 2024
Guild
MN
Finding 2024-002 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Passed through Hearth Connections and Passed through Dakota County, Continuum of Care. Assistance Listing Number: Federal Financial Assistance Listing #14.267 Program Name: Continuum of Care Progr...
Finding 2024-002 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Passed through Hearth Connections and Passed through Dakota County, Continuum of Care. Assistance Listing Number: Federal Financial Assistance Listing #14.267 Program Name: Continuum of Care Program Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: This clinical program is now under new leadership and is enhancing its controls and oversight. In addition to requiring a monthly rent checklist to be reviewed and signed off by the responsible official, an additional layer of control will be implemented by involving Finance in verifying that proper documentation is in place before rent checks are issued. The program, in collaboration with Finance, will also continue enhancing the approach to standardized documentation. Responsible Individuals: Keith Rachey - Chief Financial Officer, Tiffany Yang – Controller, Diana Harris – Director of Clinical Services Anticipated Completion Date: Completed by September 2025
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