Corrective Action Plans

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Finding 561904 (2024-002)
Significant Deficiency 2024
Corrective Action Plan: The identified conditions relate to the proper application and calculation of indirect cost rates for federal research grants. Further items relate to the assignment of the proper fringe rate for federal research grants. To mitigate future occurrences of possible incorrect ra...
Corrective Action Plan: The identified conditions relate to the proper application and calculation of indirect cost rates for federal research grants. Further items relate to the assignment of the proper fringe rate for federal research grants. To mitigate future occurrences of possible incorrect rates applied to such contracts, the College has strengthened its internal controls and oversight by reviewing and reperforming calculations. Timeline for Implementation of Corrective Action Plan: These corrective actions were implemented by spring 2025.
View Audit 357554 Questioned Costs: $1
Finding 561902 (2024-003)
Significant Deficiency 2024
Planned Corrective Action: Monthly bank reconciliations and journal entries are completed by staff accountants and reviewed by the Chief Financial Officer. Historically, this process has not been documented as files are retained electronically and our accounting software, Resman, does not offer the ...
Planned Corrective Action: Monthly bank reconciliations and journal entries are completed by staff accountants and reviewed by the Chief Financial Officer. Historically, this process has not been documented as files are retained electronically and our accounting software, Resman, does not offer the functionality of in-system approvals. In 2025, we will implement a control to document this review process. Planned Implementation Date of Corrective Actions: Fiscal year ending 12/31/25
Finding 561901 (2024-002)
Significant Deficiency 2024
management fees charged above the HUD-approved allowable limit. This overage was due to an administrative oversight in adjusting the prior year approve rate of 6.93% to 6.38%, the rate approved in 2024. Management has implemented an internal process to ensure that annual adjustments to management fe...
management fees charged above the HUD-approved allowable limit. This overage was due to an administrative oversight in adjusting the prior year approve rate of 6.93% to 6.38%, the rate approved in 2024. Management has implemented an internal process to ensure that annual adjustments to management fee rates are processed. Planned Implementation Date of Corrective Actions: Fiscal year ending 12/31/25
Planned Corrective Action: Monthly bank reconciliations and journal entries are completed by staff accountants and reviewed by the Chief Financial Officer. Historically, this process has not been documented as files are retained electronically and our accounting software, Resman, does not offer the ...
Planned Corrective Action: Monthly bank reconciliations and journal entries are completed by staff accountants and reviewed by the Chief Financial Officer. Historically, this process has not been documented as files are retained electronically and our accounting software, Resman, does not offer the functionality of in‐system approvals. In 2025, we will implement a control to document this review process. Planned Implementation Date of Corrective Action: Fiscal year ending 2025, we will implement a control to document this review process. Person Responsible for Corrective Action: Chief Financial Officer
Planned Corrective Action: Monthly bank reconciliations and journal entries are completed by staff accountants and reviewed by the Chief Financial Officer. Historically, this process has not been documented as files are retained electronically and our accounting software, Resman, does not offer the ...
Planned Corrective Action: Monthly bank reconciliations and journal entries are completed by staff accountants and reviewed by the Chief Financial Officer. Historically, this process has not been documented as files are retained electronically and our accounting software, Resman, does not offer the functionality of in-system approvals. In 2025, we will implement a control to document this review process. Planned Implementation Date of Corrective Action: Fiscal year ending 2025, we will implement a control to document this review process. Person Responsible for Corrective Action: Chief Financial Officer
Planned Corrective Action: Property managers track eligible invoices and submit periodic requests for reimbursement from replacement reserves. During a staff transition in the position, an invoice was inadvertently included in two requests. Planned Implementation Date of Corrective Action: Fiscal ye...
Planned Corrective Action: Property managers track eligible invoices and submit periodic requests for reimbursement from replacement reserves. During a staff transition in the position, an invoice was inadvertently included in two requests. Planned Implementation Date of Corrective Action: Fiscal year ended 2025, accounting will review reimbursement requests do not include duplicative invoices.
View Audit 357547 Questioned Costs: $1
Finding 561894 (2024-003)
Significant Deficiency 2024
Action taken: Effective immediately, management has implemented a control for FFATA reporting filing and review process. This adjustment ensures proper reporting and alignment with compliance requirements. Person responsible: ShaQuina Davis, Chief Operating Officer Date completed: March 12, 2025
Action taken: Effective immediately, management has implemented a control for FFATA reporting filing and review process. This adjustment ensures proper reporting and alignment with compliance requirements. Person responsible: ShaQuina Davis, Chief Operating Officer Date completed: March 12, 2025
As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended December 31, 2024. Finding 2024-001 – Significant deficiency in internal controls over compliance and noncompl...
As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended December 31, 2024. Finding 2024-001 – Significant deficiency in internal controls over compliance and noncompliance over submission of required reports: The Hospital Regulatory Agreement requires the following to be filed with HUD and Lender: (i) Annual audited financial statements from a certified public accountant or other person acceptable to HUD in accordance with program obligations. (ii) Board-certified annual financial statements within 120 days following the close of the borrower’s fiscal year if the annual audited financial statements have not yet been provided to HUD and Lender, or anytime at HUD’s and Lender’s request. (iii) Monthly unaudited financial statements 40 days following the end of the month, in accordance with program obligations, until final endorsement has occurred, or at HUD’s request. (iv) Quarterly unaudited financial statements and utilization statistics within 40 days following the end of each quarter of the borrower’s fiscal year, in accordance with program obligations. Although board approval was received prior to the due date, the annual board-certified financial statements were submitted five days (three business days) after the deadline required by the Hospital Regulatory Agreement. Management did not have effective internal controls in place to ensure the report was submitted in accordance with the Hospital Regulatory Agreement. Corrective Action Planned: Although the circumstances were unique due to implementation of a new electronic health record system, additional personnel will be involved to ensure redundancy, completion, and compliance with the annual reporting requirement. Anticipated Completion Date: 5/30/2025 Responsible Party for Corrective Action: Vince Wong, Senior Director of Finance
Finding 2024-005 Reporting – Internal Control over Reporting City will incorporate regular reconciliations of ARPA Expenditures to ensure better tracking and accurate reporting. To comply with reporting requirements the City will be revising the SLFRF reporting for the upcoming year due on April 30,...
Finding 2024-005 Reporting – Internal Control over Reporting City will incorporate regular reconciliations of ARPA Expenditures to ensure better tracking and accurate reporting. To comply with reporting requirements the City will be revising the SLFRF reporting for the upcoming year due on April 30, 2025 to reflect the appropriate amounts. Furthermore, a final reconciliation with all applicable back-up will be provided to the Finance Manager by the Finance Management Analyst for review and approval prior to submission to ensure accurate reporting. Responsible Person: Finance Manager Expected Implementation: July 1, 2025
Finding 2024-004 Procurement and Suspension and Debarment – Internal Control over Suspension and Debarment City will incorporate the Uniform Guidance requirements into a procedure in our decentralized environment to ensure the City is in compliance with the Uniform Guidance. City staff (Management A...
Finding 2024-004 Procurement and Suspension and Debarment – Internal Control over Suspension and Debarment City will incorporate the Uniform Guidance requirements into a procedure in our decentralized environment to ensure the City is in compliance with the Uniform Guidance. City staff (Management Analyst’s) will prior to contract execution access SAM.Gov to check for possible party ineligibility following and keep record of that check with the time stamped for every CIP project that is advertised for bids. All this documentation then will be compiled in the project file in both hard-copy and electronic. The Finance Management Analyst currently monitors meeting agendas as the capacity of the role entails contract management; to ensure that the process is completed., upon agenda monitoring the Finance Management Analyst will confirm with the interdepartmental Management Analyst that the SAM.Gov check was completed before contract execution. Responsible Person: Finance Manager Expected Implementation: July 1, 2025
2024-003 Staff responsible for the audit was on FMLA, along with other significant turnover in personnel, causing a late audit. This should be resolved and should not happen again in the future. We are also setting up controls to mitigate delays for the audit preparation. This should be resolved by ...
2024-003 Staff responsible for the audit was on FMLA, along with other significant turnover in personnel, causing a late audit. This should be resolved and should not happen again in the future. We are also setting up controls to mitigate delays for the audit preparation. This should be resolved by the end of the 24-25 school year.
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 29, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 29, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended February 28, 2023. Finding 2024-001 Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Rental and Cooperative Housing (Section 221(d)(4)) Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will ensure that the accounts reconcile to source documents as part of our month-end closing process. Anticipated Completion Date September 30, 2024
The Society has limited staff resources and has relied on essential staff to review and submit reports. As a result of the audit finding, the Society has established a process for documenting deadlines, reviewing and approving programmatic and financial reports before submission, and archival of doc...
The Society has limited staff resources and has relied on essential staff to review and submit reports. As a result of the audit finding, the Society has established a process for documenting deadlines, reviewing and approving programmatic and financial reports before submission, and archival of documentation in shared digital folders.
As a corrective measure, BGCPR will take the following actions and will anticipate completing on June 30, 2025: a. Implement and maintain an automated accounting and financial records system to enable real-time oversight of the asset capitalization policy. b. Establish a robust internal control fram...
As a corrective measure, BGCPR will take the following actions and will anticipate completing on June 30, 2025: a. Implement and maintain an automated accounting and financial records system to enable real-time oversight of the asset capitalization policy. b. Establish a robust internal control framework including pre-approvals for equipment purchases and cross-validations of financial data. c. Periodic internal monitoring’s to ensure compliance and documentation.d. Update BGCPR’s fiscal management guidance to include a formal provision requiring the capitalization policy to be reviewed every three (3) years in compliance with the ensure compliance with federal regulation 2 CFR §200 regarding asset capitalization criteria. e. Conduct a training program for accounting and financial personnel.
As a corrective measure, BGCPR will take the following actions and will anticipate completing on June 30, 2025: a. Develop and adopt a procurement checklist to be completed and reviewed before any purchase is approved. b. Use the checklist to verify compliance with technical, budgetary, and legal re...
As a corrective measure, BGCPR will take the following actions and will anticipate completing on June 30, 2025: a. Develop and adopt a procurement checklist to be completed and reviewed before any purchase is approved. b. Use the checklist to verify compliance with technical, budgetary, and legal requirements c. Establish rigorous mechanisms for the authorization, review, and documentation of all purchases. d. Implement monitoring procedures to control at every stage of the procurement process—from solicitation to award.
View Audit 357482 Questioned Costs: $1
Audit period: The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule of expenditures of federal awards. Finding 2024-001 – COVID 19 – Coronavirus State and Local Fiscal Recov...
Audit period: The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule of expenditures of federal awards. Finding 2024-001 – COVID 19 – Coronavirus State and Local Fiscal Recovery Fund - AL No. 21.027 U.S. Department of Treasury Other Matters Related to Internal Control over Compliance of the Major Program Criteria: Non‐federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. Condition and Context: During our testing as it related to compliance with procurement we noted that an expense for engineering services for the Waste Water Treatment Assessment services charged to the major program would have required a formal bidding process as the project exceeded the simplified acquisition threshold. The Town had selected the engineering company for “On Call” engineering services as it related to the DPW through a request for qualifications process. The contract does include as part of the services to be provided Waste Water Treatment Assessment services. However, the contract is not specific to federally funded projects. The Town of Medfield had submitted the request for qualifications documentation as well as the executed contracted for “On Call” services to both the Town’s consulting service and the pass through entity for approval of the Waste Water Treatment Assessment. The pass through entity and the pass through entities Auditors did not have any concerns with the request for qualifications as it relates to the Waste Water Treatment Assessment project. Questioned Costs: $40,500 Cause: Based on the judgement of the pass through entity (Norfolk County) and their auditors, the Town was approved to procure engineering services for the Waste Water Treatment Assessment as part of a larger “On Call” services contract. The Town did select the contractor through a competitive request for qualifications process, but did not initiate a separate procurement for the sub-project. Effect or Potential Effect: There is risk that amounts charged to the federal awards major program may not be in accordance with procurement, suspension, and debarment principles. Identification as a Repeat Finding: N/A Recommendation: Going forward, the Town of Medfield should consider a separate bidding process for expenses related to federal grant funds. Responsible for Corrective Plan: Contact Person: Kristine Trierweiler, Town Administrator Estimated Completion Date: April 30th, 2025 Action Taken: On an ongoing basis, the Town will initiate separate procurements for projects covered under federal grants.
View Audit 357437 Questioned Costs: $1
The District will implement a process to track the submission time of the data collection from and audit package.
The District will implement a process to track the submission time of the data collection from and audit package.
2024-002 – Indirect Costs Auditor Description of Condition and Effect. During our testing of indirect cost rates we observed that overhead was included in the Institute's indirect cost rate reimbursement calculation for one out of the Institute's three indirect cost calculations (the general and adm...
2024-002 – Indirect Costs Auditor Description of Condition and Effect. During our testing of indirect cost rates we observed that overhead was included in the Institute's indirect cost rate reimbursement calculation for one out of the Institute's three indirect cost calculations (the general and administrative calculation). As a result of this condition, the Institute did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation. We recommend that the Institute review its policies and procedures in regard to the review of the calculation of indirect costs reimbursement to ensure that it conforms with the approved indirect cost rate and all provisions of the indirect cost rate approved by the Institute's cognizant agency. Corrective Action. Altarum’s indirect rate agreement with the Federal government is a provisional rate agreement, meaning the rates and their bases are not yet finalized. Under FAR Subpart 42.7, Altarum has the flexibility to propose the rates, and their bases provided we comply with the FAR. The following FAR clauses address flexibility:  Indirect Cost Rates: Under FAR 42.703-1, companies must accumulate indirect costs in logical groupings and allocate them using a base that reflects the benefits accruing to cost objectives. This ensures fairness and consistency in cost allocation.  Flexibility: FAR Subpart 42.7 provides flexibility in cost allocation methods, particularly under FAR 42.705 (Final Indirect Cost Rates). This section allows companies to adjust indirect cost allocation methods in response to significant changes in business operations or other relevant circumstances.  Certification: The requirement for contractors to certify their indirect cost proposals is detailed in FAR 42.703-2 (Certificate of Indirect Costs). This ensures compliance with applicable regulations and establishes the validity of the cost proposals. In June 2024, Altarum submitted a certified indirect rate proposal utilizing the total cost input method, excluding subrecipients over $25,000, as the base for our general and administrative (G&A) cost pool. This base was chosen to reflect the benefits accruing to those cost objectives. The accompanying proposed rate Altarum submitted reflected this calculation. Our provisional G&A rate was approved at the percentage that included overhead in our G&A base. However, the narrative in our provisional nonprofit rate agreement did not accurately reflect our proposal, as it inadvertently included the term "total direct costs" when describing the base for the G&A rate. For the fiscal year 2024, Altarum incorporated overhead costs into the base of the associated general and administrative cost rate as certified in our proposal to the Federal government in June 2024. To address the discrepancy between the provisional rate agreement, our proposal, and our system, we sought guidance from our cognizant agent at US Department of Health and Human Services (HHS). In discussions, Altarum was advised to update the allocation base as part of our next proposal package submission, June 2025. Additionally, we were advised that the reviewer from HHS will update the allocation base when finalizing the indirect cost rates for fiscal year 2024. Altarum will follow the advice of HHS and resolve the discrepancies in the rate agreement later this year. Responsible Person. Denise Sturm Anticipated Completion Date. 6/30/2025 – submissions to Federal government; final resolution subject to DHHS's review of our submissions.
View Audit 357424 Questioned Costs: $1
Finding 561752 (2024-004)
Significant Deficiency 2024
Finding #2024-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contrac...
Finding #2024-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost compliance – all major programs. In a sample of 59 non-payroll transactions tested for internal controls over compliance: One instance of annual advertising contract charged in full rather than establishing a prepaid expense for the eleven months after Civic Heart’s year-end of August 31, 2024. The applicable grant period is July 1, 2023 through June 30, 2025 and thus, only one month, or approximately $417, was outside the period of performance (AL #93.767 Children’s Health Insurance Program). One instance of $2,700 charged to wrong program. Allowable costs of the Navigator program were charged to Connecting Kids program due to coding to the wrong class code in the general ledger. (AL#93.767 Children’s Health Insurance Program (Connecting Kids). In a sample of 135 payroll transactions tested for internal controls over compliance: Four instances of errors in the amount of costs charged to class code due to a clerical error in the payroll allocation spreadsheet. (AL #93.959 Block Grants for Prevention and Treatment of Substance Abuse and AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based). Other non-compliance: AL #93.767 Children’s Health Insurance Program: In a sample of 40 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($417). AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 42 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($2,700). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based: In a sample of 40 payroll or vendor charges, two instances of non-compliance with allowable costs due to charge to the wrong program. Controls over period of performance – all major programs. In a sample of 56 vendor transactions and 4 pay periods with grant beginning or ending dates during the audit period, we found: 13 instances of charging vendor costs to the wrong grant period. One instance of charging payroll costs to the wrong grant period. Other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 14 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $3,120). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based. In a sample of 27 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $480). In a sample of four pay periods tested, we found one exception for charging costs to the wrong grant period (approximately $5,350). AL# 93.959 Block Grants for Prevention and Treatment of Substance Abuse. In a sample of 25 vendor charges tested, we found 5 exceptions for charging to the wrong grant period (approximately $660). Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance of payroll spreadsheets and reviews of coding for all transactions. Planned corrective action: Adherence to established policies and procedures will be strengthened by providing additional training when onboarding accounting staff, as well as additional oversight to the disbursement and payroll process. New accounting staff will be more thoroughly trained on established policies and procedures, including accruals, proper financial statement period recognition, grant award period of performance, tracking of grant activities using class codes, and allowable cost requirements. In addition, the CFO will ensure sufficient time is dedicated to reconciling payroll spreadsheets, payroll allocations, period of performance, and payroll accruals. Salaries and wages charged to the grant are now based on actual work performed determined by hours submitted by employee and approved by the applicable supervisor; this new control should assist in mitigating posting errors related to incorrect grants and grant periods. Responsible officer: Angelica Castillo, CFO. Estimated completion date: June 30, 2025.
View Audit 357417 Questioned Costs: $1
Finding 561750 (2024-003)
Significant Deficiency 2024
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 003 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25...
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 003 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25, as required, and work with the USDA to determine what reserve accounts are required, or to the extent they are not required, properly document that understanding in writing with the USDA. Action taken in response to finding: The Hospital will continue to make operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25 and has worked with the USDA to agree to the reserve funding requirements. Name of the contact person responsible for corrective action: Michael Durr, Interim Chief Financial Officer. Planned completion date for corrective action plan: December 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Michael Durr, Interim Chief Financial Officer at (417) 257 - 5801.
We now have a better understanding of what is considered public works versus equipment. Public Works bids will be let for all items that fall under the Public Works definition. We have since conducted internal training on Public Works definitions.
We now have a better understanding of what is considered public works versus equipment. Public Works bids will be let for all items that fall under the Public Works definition. We have since conducted internal training on Public Works definitions.
View Audit 357383 Questioned Costs: $1
City to correct the noted deficiencies through additional review process: • The Finance Department and Grants Management will train additional staff to mitigate the effect of the staff turnover.
City to correct the noted deficiencies through additional review process: • The Finance Department and Grants Management will train additional staff to mitigate the effect of the staff turnover.
The District will implement a process to track the submission time of the data collection form and audit package.
The District will implement a process to track the submission time of the data collection form and audit package.
2024-001 - Reporting Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation will ensure records are reconciled and available for...
2024-001 - Reporting Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation will ensure records are reconciled and available for audit within a timely manner of year end. Planned implementation date of corrective action: May 27, 2025
Planned Corrective Action: The Seattle Indian Health Board has adopted a sliding fee program that provides discounts to eligible patients and Indian tribes. To address the auditors' concerns and further strengthen our internal controls, we are implementing a comprehensive corrective action plan. Fir...
Planned Corrective Action: The Seattle Indian Health Board has adopted a sliding fee program that provides discounts to eligible patients and Indian tribes. To address the auditors' concerns and further strengthen our internal controls, we are implementing a comprehensive corrective action plan. Firstly, we will ensure that all personnel involved in eligibility checks, including front desk staff and benefits specialists, are fully trained and aware of federal regulations and internal policies. This will be achieved through comprehensive training sessions and the development of a detailed training manual outlining eligibility criteria, documentation requirements, and procedural steps. Periodic refresher training sessions will reinforce adherence to these policies. Secondly, we will establish a robust internal audit system to regularly review and verify compliance with eligibility requirements. This includes integrating a monthly audit of eligibility determinations into the month-end reporting process, conducted by the clinical operations team. The clinical operations team will use a standardized checklist during these audits to ensure consistency and thoroughness. They will document findings and follow up on any issues or discrepancies with the relevant personnel to ensure timely corrections and adherence to procedures. Management believes that we have adequate internal control systems to safeguard the organization's assets and comply with federal and local regulations. However, we remain committed to further strengthening our controls and processes where necessary. Name of Responsible Party: Mary Kelley, Director of Revenue Cycle Anticipated Completion Date: September 30, 2025
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