Corrective Action Plans

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Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures...
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures claimed for reimbursement and retains this documentation along with supporting invoices. A qualified, knowledgeable CFO will continue to ensure compliance with these requirements. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
2025-003 Period of Performance (repeat of finding 2024-005) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will monitor expenses, and a separate prepaid schedule ha...
2025-003 Period of Performance (repeat of finding 2024-005) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will monitor expenses, and a separate prepaid schedule has been developed to track future period expenses. OMC’s current CFO/Designee has a basic understanding of GAAP. All coding will be reviewed and approved by an authorized, knowledgeable CFO/Designee. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393 Questioned Costs: $1
2025-002 Allowable Costs/Cost Principles (repeat of finding 2024-004) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will continue to monitor to assure compliance w...
2025-002 Allowable Costs/Cost Principles (repeat of finding 2024-004) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will continue to monitor to assure compliance with documentation for all federal expenditures, whether payroll or procurement transactions. All supporting documentation is currently being retained electronically and linked to the corresponding transaction in the financial system. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393 Questioned Costs: $1
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
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 fe...
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 will 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. Management meetings will be scheduled with the COO, Director of Operations, and Dental Billing Supervisor(s) to provide updates on progress. Periodic internal auditing of sliding fee scale dental files will be completed. Quarterly management review of sliding fee scale program progress until Athena Dental is fully integrated with Athena Medical, where electronic health record issues were not detected regarding sliding fee scale adjustments. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kevin Maddox, CFO, at 636-236-5180
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained re...
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained relating to fiscal year 2025. Uniform Guidance requires the Organization to be in compliance with special tests and provisions. This includes maintaining appropriate documentation of the application and fee determination for every patient utilizing the sliding fee discount. This is a repeat of finding 2024-003 from the prior year. One error was identified during our testing. Expanded procedures identified that the population impacted were four individuals. The amount of questioned costs cannot be determined. A sample of 40 individuals were selected and tested for compliance with the Organization's sliding fee policy. One (1) known compliance error was found during testing of the 40 individuals. Upon analyzing the entire population, it was determined that a total of four (4) files were not in compliance. The Organization was not in compliance with the requirements of the federal program due to a scanner malfunction where the application and supporting documentation were not adequately scanned, resulting in a corrupt file. Cause: Management has indicated that the scanner malfunction lead to the noncompliance. Upon the realization of the scanner issue, it was replaced and an analysis was performed for any other patient files that may have been corrupted. Management review of the entire population identified a total of (4) four files that were corrupt relating to fiscal year 2025. Corrective Response: Management is in agreement with the above analysis by the auditors. The issue was discovered and corrected with an update to the server and an update to the process to ensure that all scans are reviewed prior to the destruction of the original documents. This was fully resolved prior to the fiscal year end. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: CFO/Revenue Cycle Director/Director of Clinical Ops/Vice President of IT
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
View Audit 365848 Questioned Costs: $1
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
View Audit 365848 Questioned Costs: $1
Finding 575602 (2025-004)
Significant Deficiency 2025
Finding 2025-004: Coronavirus State and Local Fiscal Recovery Funds Reporting Procedures Type of Finding: Control U.S. Department of Treasury Pass-through Entities: The Right Place, Inc. and Michigan Department of Treasury. Assistance Listing Number: 21.027 Award Numbers: COVID-19 Revitaliza...
Finding 2025-004: Coronavirus State and Local Fiscal Recovery Funds Reporting Procedures Type of Finding: Control U.S. Department of Treasury Pass-through Entities: The Right Place, Inc. and Michigan Department of Treasury. Assistance Listing Number: 21.027 Award Numbers: COVID-19 Revitalization and Placemaking Grant, COVID-19 American Rescue Plan Act Award Year End: June 30, 2026 and December 31, 2026 Specific Requirement: (L.) Reporting Recommendation: The Village should follow established procedures to require the documented review and approval of both RAP and ARPA grant reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Village is implementing a new procedure requiring that ARPA grant reports be reviewed and approved by a designated reviewer before submission in addition to RAP grant reports. The reviewer, who must possess the appropriate skills, knowledge, and experience relevant to the report's content, will ensure that the information is accurate, complete, and compliant with organizational standards and regulatory requirements. Responsible Person and Anticipated Completion Date: The Village Clerk/Treasurer will oversee the implementation of this plan by February 28, 2026. If the Michigan Strategic Fund has questions regarding this plan, please call Phillip Morse at 231-861-4401.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Finding 575411 (2025-002)
Significant Deficiency 2025
Views of Responsible Officials and Planned Corrective Actions – To address the identified issues related to student withdrawal processing and Return to Title IV (R2T4) calculations, the University will implement the following steps: 1. Process Review and Collaboration: A joint meeting will be held w...
Views of Responsible Officials and Planned Corrective Actions – To address the identified issues related to student withdrawal processing and Return to Title IV (R2T4) calculations, the University will implement the following steps: 1. Process Review and Collaboration: A joint meeting will be held with key personnel from Academic Records and Financial Aid to review current withdrawal procedures, including the use of drop and exit forms. Emphasis will be placed on ensuring that appropriate withdrawal codes are consistently applied to support accurate and automated R2T4 processing. The goal is to establish a unified and clearly documented process that meets the operational needs of both departments. 2. Systematic Scheduling and Monitoring: Withdrawal-related tasks, including the running of BANNER return reports and other custom reports developed by the IT team, will be scheduled at regular intervals to ensure timely identification and processing of student withdrawals. These tasks will be integrated into departmental calendars, with scheduled dates already entered for the Fall 2025 and Spring 2026 semesters. 3. Ongoing Oversight and Communication: A communication protocol will be developed to ensure that all relevant documentation, including drop forms, is consistently shared between departments. This will help prevent delays in processing and ensure compliance with federal financial aid regulations.
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residua...
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residual receipts deposit is made within 90 days of fiscal year end. Management response: Agree. Management made the required residual receipts deposit on January 8, 2025.
View Audit 365221 Questioned Costs: $1
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacem...
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacement account . Response: Management agrees with the finding and has refunded $1,707 to the Reserve for Replacement Account on August 12, 2025.
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for ...
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for other operating expenses were made from the Reserve for Replacement account without prior approval from the lender. Response: Management agrees with the finding, was aware of the requirement for prior approval and on April 30, 2025, and has obtained retroactive approval from the lender for the withdrawal of 108,111.
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2025 Estimated Completion Date: September 2025 Finding #2025-001 – Statement of Condition Patients did not receive the proper sliding f...
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2025 Estimated Completion Date: September 2025 Finding #2025-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. The Office Managers have continued reviewing all new sliding fee applications on a monthly basis to ensure accuracy. The Billing Manager have continued to conduct quarterly audits of sliding fee claims to ensure the adjustments are entered correctly by the billing department. The Organization has also launched additional training for all individuals involved in the sliding fee application process as well as automated sliding fee adjustments to reduce errors.
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
View Audit 363992 Questioned Costs: $1
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS appli...
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
Finding 572937 (2025-002)
Significant Deficiency 2025
Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned i...
Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has made the missing deposit as of March 31, 2025. Name of the contact person responsible for corrective action: Laurie Rudman, Senior Vice President, CFO Planned completion date for corrective action plan: March 31, 2025
View Audit 363778 Questioned Costs: $1
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 A...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: March 31, 2025. The finding from the March 31, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project overpaid management fees to the management company. Recommendation: The management company should reimburse the Project for the $755 overpayment. Action Taken: The Project agrees with the finding. The management company will repay the overpaid management fee as soon as possible. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.
View Audit 363740 Questioned Costs: $1
Finding 572429 (2025-001)
Significant Deficiency 2025
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non...
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2025, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware...
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware that such an advance was not permitted to be made. Kane Financial Services was also unaware. The plan to correct it includes the following action steps: • Seeking approval from HUD for the $2.7M advance. • If the advance is not approved, then the repayment will occur by the organizations over an 18-month period beginning in October 2025. It is understood that such advances will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: Sshain@kanefs.com Phone: 561-223-4161 Sincerely, Susan Shain Executive Vice President of Finance Kane Financial Services
View Audit 363196 Questioned Costs: $1
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with th...
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will remind staff of the proper procedures for dissemination of EIV information.
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