Corrective Action Plans

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Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 370864 Questioned Costs: $1
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
View Audit 370864 Questioned Costs: $1
Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 370864 Questioned Costs: $1
Finding Number: 2024-003 Planned Corrective Action: Management acknowledged the sliding fee adjustment errors resulted from incorrect calculation of sliding fee discount. Management will add an additional layer of review over the application of the sliding fee scale. Further, the Organization will i...
Finding Number: 2024-003 Planned Corrective Action: Management acknowledged the sliding fee adjustment errors resulted from incorrect calculation of sliding fee discount. Management will add an additional layer of review over the application of the sliding fee scale. Further, the Organization will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Finding Number: 2024-002 Planned Corrective Action: Management acknowledged several amendments were made to the UDS tables that support the calculation that was filed. A lack of document retention resulted in the final amended calculation not being saved in a central, shared site that would support ...
Finding Number: 2024-002 Planned Corrective Action: Management acknowledged several amendments were made to the UDS tables that support the calculation that was filed. A lack of document retention resulted in the final amended calculation not being saved in a central, shared site that would support the amount filed. In future periods, management will have processes and procedures in place to require proper retention of reconciliation and tie-out of supporting documentation to final filings which will alleviate this finding. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Finding 2024-02 Failure to Follow Procurement Policy Condition: The Organization maintains a procurement policy that establishes spending thresholds and outlines the requirements for obtaining rate quotations at each of these levels. During audit procedures, it was noted that the Organization did no...
Finding 2024-02 Failure to Follow Procurement Policy Condition: The Organization maintains a procurement policy that establishes spending thresholds and outlines the requirements for obtaining rate quotations at each of these levels. During audit procedures, it was noted that the Organization did not follow the policy’s requirements for obtaining and documenting rate quotations for two of the transactions reviewed. The Organization explained that the vendor was considered a unique partner, and competition was intentionally limited based on the specialized nature of the services provided. However, no documentation was retained to justify this decision to limit competition, as required by federal procurement standards. The absence of such documentation resulted in questioned costs for these transactions. Corrective Actions Taken or Planned: Prior to the award of ARPA grant funding in 2023, The Organization did not have a formal procurement policy in place. Implementation of such a policy was required to receive the award. At the time of implementation, however, partnerships had already been established and were identified in the original grant proposal. With respect to legal services, the Organization engaged the two primary organizations in Indianapolis that provide expungement assistance. Indiana Legal Services (“ILS”) was the first entity contacted, but after multiple attempts, no response was received from the designated point of contact. Subsequently, the Organization engaged another nonprofit organization, which responded promptly and agreed to serve as a partner under the grant. For grant compliance services, the Organization engaged a third party. This decision was based on recommendations from community partners, as well as her demonstrated work quality, professional reliability, and commitment to serving the target population. The Organization plans to execute the following: 1. Immediate Remediation - For the two transactions in question, the Organization will prepare and retain retroactive documentation outlining the rationale for limiting competition, citing the vendor’s unique qualifications and specialized services. This documentation will be added to the procurement files to ensure transparency and compliance. 2. Procurement Policy Enforcement - The Organization will reinforce its procurement policy with staff responsible for purchasing, emphasizing the following requirements: - Obtain and document at least three rate quotations when required. - When limiting competition, prepare a written justification memo explaining the rationale (e.g., sole source, specialized expertise, emergency procurement). - Retain all procurement documentation in a centralized file accessible for future audits. 3. Documentation Standardization - A Procurement Justification Form will be developed for instances where competition is intentionally limited. This form will include: + Vendor name and description of services + Reason competition is limited (sole source, unique expertise, etc.) + Approval signatures from both the requesting program lead and the Co-Executive Director - This form will be required for all procurements exceeding the competitive threshold where quotations are not obtained. 4. Staff Training - The Organization will provide refresher training to all staff involved in procurement to ensure they fully understand documentation requirements under both organizational policy and federal standards. - Training will specifically address scenarios involving sole source or unique vendor selections. 5. Oversight & Monitoring - All procurements exceeding $5,000 will require review and approval by the Board. - Quarterly internal audits will be performed by the Finance Manager to ensure procurement files include proper quotations or justification forms. The Board will receive quarterly procurement compliance reports from the Finance Manager. Any deviations will be documented and addressed immediately. Progress will be tracked as part of the Organization’s annual internal control review.
View Audit 370779 Questioned Costs: $1
Management’s Response/Corrective Action Plan (Unaudited): The City acknowledges the finding and is committed to strengthening internal controls over compliance for the review and approval of grant-related expenditures. Effective immediately, the City implemented the following corrective measures: 1....
Management’s Response/Corrective Action Plan (Unaudited): The City acknowledges the finding and is committed to strengthening internal controls over compliance for the review and approval of grant-related expenditures. Effective immediately, the City implemented the following corrective measures: 1. Formalized Invoice Review and Approval Process o All grant-related invoices to undergo documented review and approval before the preparation and disbursement of funds. o The procedure will require reviewers to sign and date each invoice (either physically or electronically) to provide a verifiable audit trail. 2. Assignment of Review Responsibility o Designate a primary reviewer and a backup reviewer within the Finance Department to ensure continuity of compliance in the event of staffing turnover. o Review responsibility will be incorporated into the official job descriptions of these positions. 3. Training and Staff Development o Conduct mandatory training for all finance and grant administration personnel on the disbursement review process, compliance requirements under 2 CFR 200.303, and documentation retention protocols. o Training will be provided within 30 days of hire for all new staff assigned to the process. 4. Periodic Monitoring and Quality Checks o Implement quarterly internal reviews by the Finance Director (or designee) to verify adherence to the review and approval process. o Findings from these internal reviews will be documented and corrective steps taken promptly if deficiencies are noted. Planned Completion Date: Implementation and training of this plan is complete. Contact Person Responsible for Correction Action: Finance Director
Corrective Action Plan & Response: RCRHA concurs with this finding and is taking comprehensive steps to address the issue and prevent recurrence. Specifically: 1. Revisiting AMA Consulting Group Proposal:_x000B_RCRHA is in the process of revisiting a formal proposal previously received from AMA Cons...
Corrective Action Plan & Response: RCRHA concurs with this finding and is taking comprehensive steps to address the issue and prevent recurrence. Specifically: 1. Revisiting AMA Consulting Group Proposal:_x000B_RCRHA is in the process of revisiting a formal proposal previously received from AMA Consulting Group, LLC, which outlines a detailed "Agency Health Check" for our Public Housing program. This proposal includes: • An operational audit of tenant files and eligibility documentation • Process mapping to improve workflow and accountability • Quality control implementation • Recommendations for electronic file storage and ongoing compliance monitoring.Engaging AMA is part of our long-term strategy to modernize internal operations and improve compliance. 2. Recent Staff Training: Nan McKay Rent Calculation Course:_x000B_To immediately address gaps in eligibility documentation practices, RCRHA staff participated in the Nan McKay HCV and Public Housing Rent Calculations Course in Washington, NC._x000B_The three-day seminar provided comprehensive instruction in: • Income and asset verification under 24 CFR Part 5 • Adjusted income and allowable deductions • Total Tenant Payment (TTP) calculations for both HCV and Public Housing • Case study applications using HUD Form 50058.3. Internal File Review and Compliance Checklist Implementation:_x000B_RCRHA has initiated a review of all active Public Housing tenant files to ensure that required eligibility documents are present, accurate, and properly stored. A standardized checklist is being introduced to guide staff and ensure uniform compliance across all tenant records. 4. Electronic File System Evaluation:_x000B_In alignment with HUD best practices and our consultant's recommendation, RCRHA is evaluating the feasibility of transitioning to an electronic document management system to ensure long-term retention, audit readiness, and streamlined access to eligibility documentation. 5. Revised Calendar: RCRHA has revised their audit calendar that will begin no later than October following the fiscal year. Internal accounting has been briefed on the matter and will have additional oversight in place to monitor that audit timelines. The Board of Commissioners will monitor audit timelines and reporting schedules. 6. SEFA Preparation: There will be detailed cross walks performed by CFDA numbers that include program specific reporting requirements. Internal accounting will receive additional training in federal grant reporting and a review will be performed by the CEO and a second-level review will be performed by the external accounting consultant.RCRHA is committed to addressing the current findings with a multi-layered response that strengthens documentation procedures, promotes staff competency, and enhances our operational efficiencies.
Finding 2024-002 Management Response: The Business Manager has year-end procedures in place to ensure year end adjusting entries are performed prior to the audit. Individual Responsible: Corrina Lesko Anticipated Completion Date: October 1, 2025
Finding 2024-002 Management Response: The Business Manager has year-end procedures in place to ensure year end adjusting entries are performed prior to the audit. Individual Responsible: Corrina Lesko Anticipated Completion Date: October 1, 2025
Finding 2024-003 Material Weakness in Internal Control Over Special Tests and Provisions 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,...
Finding 2024-003 Material Weakness in Internal Control Over Special Tests and Provisions 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 2024 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, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 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 December 30, 2025. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615.
Finding 2024-002 Material Weakness in Internal Control Over Reporting 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 a...
Finding 2024-002 Material Weakness in Internal Control Over Reporting 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 2024 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, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 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, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist.• The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • All grant related year-end audit procedures have been transitioned to the Grant Accountant who has experience with financial audits and compliance and reporting for City, State, and Federal grants. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • 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 and the Universal Report. The target date for full implementation of these corrective actions is December 30, 2025. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615. • 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 timely submission of Federal Financial Reports (FFR) to HRSA, Friend Health will implement a robust internal calendar that includes all HRSA reporting deadlines along with earlier internal due dates for preparation and review. Designated financial and grants management staff will be responsible for compiling and verifying the required data well in advance of the submission deadline. Friend Health will conduct regular internal reviews to ensure accuracy, completeness, and compliance with HRSA guidelines. Additionally, staff will be provided with ongoing training on HRSA reporting requirements and utilizing reporting tools or software that streamline the FFR preparation process. These proactive measures will help maintain compliance and prevent future delays. • The Organization will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies.
Recommendation: We recommend that management timely submit annual audit report to the Federal Audit Clearinghouse. To do this, management should develop and implement a clear timeline with internal milestones for completing audit preparation and review. Management should also establish internal cont...
Recommendation: We recommend that management timely submit annual audit report to the Federal Audit Clearinghouse. To do this, management should develop and implement a clear timeline with internal milestones for completing audit preparation and review. Management should also establish internal control procedures that assign specific responsibilities to staff to ensure that all federal reporting deadlines are met. Views of Responsible Official: Management of the Organization concurs with the audit finding and will immediately implement the auditors’ recommendations. Internal control procedures will be put into place to establish milestones and overseen by the Executive director
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: July 1, 2025 Views of Responsible Officials and Planned Corrective Action: Unfortunately, due to the late completion of ...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: July 1, 2025 Views of Responsible Officials and Planned Corrective Action: Unfortunately, due to the late completion of the 2023 Single Audit and the hiring of the grants position in early 2025, many previous findings and contracts were not yet corrected in 2024. In the event of this finding, there were two vendors which had minimal expenditures in 2024 (under $5,000 which does not require competitive bids but in aggregate they exceeded that amount). The procurement department had not been consulted, and debarment checks were not completed when the work began in 2023, and final payments were issued in 2024. In the Grants Manual and training departments have been instructed that these procedures must be complied with for all grants.
View Audit 370644 Questioned Costs: $1
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: The grants administrator has been developi...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: The grants administrator has been developing a master calendar and will ensure the departments file the required reports within the required timeframes of their funders and maintain copies in a centralized file.
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs o...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs over $30,000 will be reported in the FSRS system. Departments will enter the subrecipients into this system, and our grant administrator will audit the files to ensure proper documentation is maintained to ensure compliance.
The Health Department agrees with the finding and will implement the following corrective actions: Grant Monitoring Procedures: Develop and implement procedures to identify and monitor grant agreement changes and their potential impacts on established grant requirements and internal procedures. Repo...
The Health Department agrees with the finding and will implement the following corrective actions: Grant Monitoring Procedures: Develop and implement procedures to identify and monitor grant agreement changes and their potential impacts on established grant requirements and internal procedures. Reporting Procedures: Establish specific procedures to track grant reporting deadlines, review submission progress, and confirm status of upcoming reports. Staff Training and Oversight: Assign responsibility for the report preparation and submission as well as management review and confirmation of report submission.
Condition Found: Per 2 CFR § 200.512(a), the auditee must submit the data collection form (DCF) and reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report(s), or nine months after the end of the auditee’s fiscal year. The aud...
Condition Found: Per 2 CFR § 200.512(a), the auditee must submit the data collection form (DCF) and reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report(s), or nine months after the end of the auditee’s fiscal year. The audit for the year ended December 31, 2023, was not submitted to the Federal Audit Clearinghouse until DATE, which is after the required submission deadline of September 30, 2024. Individual(s) Responsible for Corrective Action: Lynda P. Goldthwaite, Executive Director and Stacey Matott, Director of Finance Planned Corrective Action: With the debt work out in place, management should continue to follow procedures in place to ensure the timely completion of future audits and submission of the reporting package to the Federal Audit Clearinghouse. Anticipated Completion Date: September 30, 2025
Condition Found: The Organization did not make the required annual deposits into the debt payment reserve, capital asset replacement reserve, resident asset depletion reserve, and the facility fill reserve. We confirmed the balances of the four reserve accounts and identified that all four reserve a...
Condition Found: The Organization did not make the required annual deposits into the debt payment reserve, capital asset replacement reserve, resident asset depletion reserve, and the facility fill reserve. We confirmed the balances of the four reserve accounts and identified that all four reserve accounts were not funded in accordance with the USDA loan agreement. Individual(s) Responsible for Corrective Action: Lynda P. Goldthwaite, Executive Director and Stacey Matott, Director of Finance Planned Corrective Action: Peabody Place sought a debt work out in 2025 that would allow for deferral of required deposits for six months until January 1, 2026. Anticipated Completion Date: Completed
View Audit 370637 Questioned Costs: $1
2024-003 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through County of Luzerne, Pennsylvania, Pass-Through Entity Identifying Number: not ...
2024-003 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through County of Luzerne, Pennsylvania, Pass-Through Entity Identifying Number: not available Assistance Listing #66.202, Congressionally Mandated Projects, United States Environmental Protection Agency, Pass-Through Entity Identifying Number: 95339501-0 Criteria: The Uniform Guidance requires written policies and/or procedures in the areas of allowability of costs and cash management. Condition/Context: While the Authority has informal policies and procedures surrounding the administration of its federal programs, these policies and procedures have not been formally documented to ensure compliance with the areas of allowability of costs and cash management as required under the Uniform Guidance. Corrective Action Plan Although the Authority currently follows the requirements of the Uniform Guidance and has informal policies and procedures as it relates to the administration of federal grant activities, the Authority will establish a formal written policy titled Uniform Guidance for Federal Grants by December 31, 2025. WVSA’s Internal Auditor, Comptroller, Purchasing Department and general business staff are overseeing and implementing the corrective actions with oversight of the CFO and CTO.
Strengthen compliance efforts and mitigate risk, staff will consult a qualified third-party professional before executing any transaction that may be unallowable, ensuring adherence to funding. If unallowable expenses are identified, staff will quickly coordinate with the appropriate state agency to...
Strengthen compliance efforts and mitigate risk, staff will consult a qualified third-party professional before executing any transaction that may be unallowable, ensuring adherence to funding. If unallowable expenses are identified, staff will quickly coordinate with the appropriate state agency to resolve issue.
View Audit 370633 Questioned Costs: $1
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of E...
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 225GA324N1099 (Year: 2024), 245GA324N1199 (Year: 2024) Questioned Costs: $46,878 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that the School District's procurement procedures were followed. Corrective Action Plans: Responsible Parties: Superintendent, School Nutrition Manager, To address this finding and prevent recurrence, the Superintendent and School Nutrition Manager will implement the following corrective measures in accordance with Terrell County Board of Education policy and applicable federal/state guidelines: 1. Staff Training-Provide training for School Nutrition staff on federal procurement requirements, the district's Procurement Plan, and Board policy related to financial management, procurement, and record retention. Training will be documented and updated annually or as requirements or Board policies are revised. 2. Process Monitoring-Establish written procedures aligned with board-approved procurement policies to ensure all required bids and quotes are obtained, documented, and retained. Maintain both electronic and hard-copy procurement files, with oversight responsibilities clearly assigned. 3. Internal Compliance Reviews-Conduct quarterly internal reviews between the Schol Nutrition Department and Finance to verify procurement documentation and adherence to Board policy and the Procurement Plan. Provide review summaries to the Superintendent and report systemic issues to the Board, if necessary. 4. Accountability Measures-Incorporate procurement documentation and retain responsibilities into departmental expectations, evaluations, and supervisory reviews, consistent with Board policies on accountability and internal controls. Noncompliance with documentation procedures will be addressed under established Board personnel and accountability policies. Estimated Completion Date: June 30, 2026 Contact Person: Shereca R. Harvey, Superintendent Telephone: (229) 995-4425 Email: srharvey@terrell.k12.ga.us
View Audit 370604 Questioned Costs: $1
Corrective action planned: In reviewing audit finding 2024-001, it was determined that the primary cause for the misapplication of the sliding fee was the need for increased training and oversight. One Health has since taken steps to enhance sliding fee policy and procedure training for all staff, w...
Corrective action planned: In reviewing audit finding 2024-001, it was determined that the primary cause for the misapplication of the sliding fee was the need for increased training and oversight. One Health has since taken steps to enhance sliding fee policy and procedure training for all staff, with a focus on Intake and Patient Financial Services staff. One Health also intends to review individual performance of staff by implementing peer and supervisory audits of sliding fee scale applications and data entry. Identification of consistent errors has led to enacting accountability measures to allow for additional coaching and follow-up. Additionally, One Health has reviewed EMR processes and functionality to ensure ease and clarity of data entry to eliminate opportunities for human error. Anticipated completion date: December 31, 2025 Contact person responsible for corrective action: Emily Faricy Associate Vice President - Finance
Client Response - During FY 2024 and part of FY 2025, the organization experienced front desk personnel turnover and operational disruptions due to facility remodeling, which required multiple relocations of staff and records. These factors contributed to gaps in the availability of supporting docum...
Client Response - During FY 2024 and part of FY 2025, the organization experienced front desk personnel turnover and operational disruptions due to facility remodeling, which required multiple relocations of staff and records. These factors contributed to gaps in the availability of supporting documentation needed to validate certain patient billing amounts. Management acknowledges the importance of retaining complete and accurate documentation to support billing, particularly for services subject to the sliding fee scale. While only a portion of the tested items were impacted, we recognize that missing documentation created the appearance of errors that could not be recalculated during audit testing. To address this, the organization is implementing corrective measures, including: • Strengthening record retention procedures to ensure all supporting documentation for billing and sliding fee scale adjustments is readily available for review. • Enhancing training for staff on billing documentation requirements tied to federal program compliance. • Establishing periodic internal reviews to confirm that billing aligns with program rules and is fully supported.
View Audit 370586 Questioned Costs: $1
DATE: September 29, 2025 TO: CBIZ FROM: CC: Nicole McGee Finance Director Joseph Devine Town Manager RE: Corrective Action for FY 2024 Finding 1 Corrective Action Plan for Finding 2024-001 “Improve Controls Over Reporting” Policies and procedures were enacted at the end of calendar year 2024 to ensu...
DATE: September 29, 2025 TO: CBIZ FROM: CC: Nicole McGee Finance Director Joseph Devine Town Manager RE: Corrective Action for FY 2024 Finding 1 Corrective Action Plan for Finding 2024-001 “Improve Controls Over Reporting” Policies and procedures were enacted at the end of calendar year 2024 to ensure there is a second person involved in the reporting process. Since then, all grant submissions must be reviewed by a second person. Expected Completion Date: December 31, 2024. Contact Person: Nicole McGee, Finance Director
The funds were subsequently returned to the account.
The funds were subsequently returned to the account.
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