Corrective Action Plans

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Condition: The Organization failed to submit the quarterly activity report as of September 30, 2024 by October 30, 2024. The report was filed November 7, 2024. Planned Corrective Action: In addition to Calendar Task Reminders (created after receiving Grant Award) assigned to various teams and manage...
Condition: The Organization failed to submit the quarterly activity report as of September 30, 2024 by October 30, 2024. The report was filed November 7, 2024. Planned Corrective Action: In addition to Calendar Task Reminders (created after receiving Grant Award) assigned to various teams and managers, ECDI will add steps in the Grant Reporting Submission process to ensure reporting deliverables are met on time. Through its CRM system, ECDI will require Report documents to be both uploaded and reviewed prior to report deadlines. ECDI will also require uploading the confirmation that the document was provided to funder/partner. After these are reviewed by Development and Fiscal leaders, then the Task will be considered complete. Contact Person Responsible for Corrective Action: David Chew and Louisa Dallett Completion Date: In process
Condition: During eligibility testing of loan disbursements under the RMAP program, one of eight disbursements tested was made to a borrower located outside of the eligible area. The loan was disbursed in fiscal year 2025 for $10,000. Planned Corrective Action: The ECDI processing and loan allocatio...
Condition: During eligibility testing of loan disbursements under the RMAP program, one of eight disbursements tested was made to a borrower located outside of the eligible area. The loan was disbursed in fiscal year 2025 for $10,000. Planned Corrective Action: The ECDI processing and loan allocation teams will not exclusively leverage it’s CRM system for determining USDA eligibility based on borrower/business address. The team will use the USDA website in determining eligibility prior to allocating USDA funds to a project. Related to the specific ineligible $10,000 USDA loan, the team has communicated to its USDA partner to make them aware of this specific issue and ECDI is in the process of removing USDA funds and replacing with another source. Contact Person Responsible for Corrective Action: Brian Barrett and Sean Henderson Completion Date: In process
Condition: During our testing of allocated salaries and wages, we identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. One employee in each program, 59.046 and 93.570, had an inappropr...
Condition: During our testing of allocated salaries and wages, we identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. One employee in each program, 59.046 and 93.570, had an inappropriate wage rate applied to allocated time to the program. Additionally, for the 59.046 program only, one employee had compensation levels allocated to the program in excess of the Executive Level II Salary maximum amount in effect for the respective period. Planned Corrective Action: ECDI will put additional steps in place related to the Payroll Review process to ensure reconciliation of payroll charges to actual time records and rates. The organization will modify its calculations to ensure that pay rates are reflective of the timeframe in question (not for periods before or after). ECDI will update its calculations to include thresholds for Executive pay so they are not entered more than approved rates. The company is also exploring technology enhancements so that information from ECDI’s Payroll system flows directly into ECDI’s Accounting system to limit the chance of errors during extraction from Payroll system and uploading into Accounting system. Contact Person Responsible for Corrective Action: David Chew and Hudu Ahmed. Completion Date: In process
High School Diploma or Equivalent Recommendation: We recommend that the District establish policies and procedures to ensure the completeness and accuracy of documentation to support the percentage of students that lack a high school diploma or its equivalent. Explanation of disagreement with audit ...
High School Diploma or Equivalent Recommendation: We recommend that the District establish policies and procedures to ensure the completeness and accuracy of documentation to support the percentage of students that lack a high school diploma or its equivalent. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: The District will provide district-level training for registrar personnel on eligibility thresholds related to reporting ratios, including the percentage of students without a high school diploma or equivalent. Training will include guidance on required documentation, verification steps, and procedures to ensure the completeness and accuracy of supporting records. Updated procedures will be shared with all registrar staff to promote consistency across campuses and ensure compliance with reporting requirements. Responsible party: Registrar, Workforce Education Planned completion date for corrective action plan: April 30, 2026 Plan to monitor completion of corrective action plan: Workforce Education leadership will conduct monthly reviews to confirm that documentation supporting eligibility ratios is complete, accurate, and aligned with established procedures. Any discrepancies identified during monthly reviews will be addressed with registrar staff to ensure ongoing compliance and continuous improvement.
Gramm-Leach-Bliley Act Recommendation: We recommend that the District update its written information security program to ensure it includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: ...
Gramm-Leach-Bliley Act Recommendation: We recommend that the District update its written information security program to ensure it includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: The District will review and update its written information security program to ensure all required elements are included and fully aligned with applicable state and federal requirements. Updates will be completed and implemented in coordination with the appropriate departments to ensure compliance and ongoing monitoring. Responsible party: Director of Network Operations & Senior Director of Information Services Planned completion date for corrective action plan: April 30, 2026 Plan to monitor completion of corrective action plan: • The Director of Network Operations and Senior Director of Information Services will conduct periodic reviews to verify that updates to the information security program are completed, documented, and implemented as intended. • Progress will be reviewed with relevant departments to ensure ongoing compliance and to address any gaps identified during implementation.
240 Day Outstanding Payments Recommendation: We recommend the District implement a review process for outstanding student payments to ensure any that include Title IV funds are refunded to the U.S. Department of Education within 240 days. Explanation of disagreement with audit finding: There is no d...
240 Day Outstanding Payments Recommendation: We recommend the District implement a review process for outstanding student payments to ensure any that include Title IV funds are refunded to the U.S. Department of Education within 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: The Financial Aid Coordinator will create and maintain a SharePoint spreadsheet to effectively track and monitor outstanding student payments. The Workforce Finance Department will support the setup and ensure the spreadsheet aligns with established financial monitoring practices. Responsible party: Financial Aid Coordinator and Workforce Finance Department Planned completion date for corrective action plan: April 30, 2026 Plan to monitor completion of corrective action plan: The Financial Aid Coordinator and Workforce Finance Department will conduct monthly reviews to ensure the spreadsheet is updated, accurate, and used consistently for monitoring outstanding payments.
Special Tests and Provisions Recommendation: It is recommended that the District strengthen its internal controls over the R2T4 calculation process by implementing a secondary review or quality-assurance check of scheduled clock hours prior to finalizing R2T4 calculations. Staff should receive targe...
Special Tests and Provisions Recommendation: It is recommended that the District strengthen its internal controls over the R2T4 calculation process by implementing a secondary review or quality-assurance check of scheduled clock hours prior to finalizing R2T4 calculations. Staff should receive targeted training on the requirements of 34 CFR § 668.22, particularly regarding the use of scheduled hours in determining earned aid and post-withdrawal disbursement eligibility. Additionally, standardized calculation worksheets or system-generated hour reports should be utilized to reduce reliance on manual entry and minimize the risk of human error. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: Financial Aid Coordinators from both technical colleges will collaborate to review and audit each other's RT24 calculations to ensure accuracy, accountability, and compliance with regulatory requirements. Responsible party: Financial Aid Coordinator Planned completion date for corrective action plan: April 1, 2026 Plan to monitor completion of corrective action plan: Monthly meetings with the Workforce Finance Department will be held to review RT24 calculations, address discrepancies, and confirm ongoing compliance.
Return to Title IV Recommendation: We recommend that a process is put in place to ensure that all students are notified upon withdrawal they may be required to return federal award funds back to the Department of Education. Explanation of disagreement with audit finding: There is no disagreement wit...
Return to Title IV Recommendation: We recommend that a process is put in place to ensure that all students are notified upon withdrawal they may be required to return federal award funds back to the Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: The District will develop a letter in FOCUS that would automatically generate and notify all students when they are required to return funds to the Department of Education Responsible party: Financial Aid Coordinator, Workforce Finance Department Planned completion date for corrective action plan: April 30, 2026 Plan to monitor completion of corrective action plan: The Financial Aid Coordinator and Workforce Finance Department will conduct monthly reviews to confirm the automated notification process is functioning correctly and that required letters are being sent and documented.
Title IV Credit Balances Recommendation: We recommend that the District review its policies and procedures for Title IV credit balances to ensure they are paid in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in resp...
Title IV Credit Balances Recommendation: We recommend that the District review its policies and procedures for Title IV credit balances to ensure they are paid in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: District has already implemented a plan by creating a drawdown process to ensure both the Financial Aid Coordinator and the Workforce Finance Department are in communication with each other. The drawdown process ensures that funds are received by the student in a timely manner (within 14 days) Responsible party: Financial Aid Coordinators, District Workforce Finance Department Planned completion date for corrective action plan: Task is completed Plan to monitor completion of corrective action plan: The Financial Aid Coordinator and Workforce Finance Department will hold monthly meetings to review the drawdown process and confirm continued compliance.
Eligibility Recommendation: We recommend that a process be implemented to ensure the proper cost of attendance is used so that amounts awarded do not exceed calculated financial need. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in ...
Eligibility Recommendation: We recommend that a process be implemented to ensure the proper cost of attendance is used so that amounts awarded do not exceed calculated financial need. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: • The Financial Aid Coordinator will ensure that when a correction is made during the disbursement process a new award letter is created • If a change is made, the Financial Aid Coordinator will enter the required information and print out a new award letter and have the student sign the form. After the form is signed by the student, the Financial Aid Coordinator will have an administrator to verify the with signature • One administrator will attend Financial Aid training to one training session to support legal and regulatory compliance Responsible party: Financial Aid Coordinators, Administrators, Workforce Finance Department Planned completion date for corrective action plan: April 30, 2026 Plan to monitor completion of corrective action plan: The Financial Aid Coordinators, Administrators, and Workforce Finance Department will conduct a monthly review to confirm that revised award letters are issued, signed, verified, and properly documented.
Documentation of Monthly Reconciliation Recommendation: We recommend the District establish policies and procedures to ensure proper documentation of preparation and review of monthly Title IV reconciliations. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...
Documentation of Monthly Reconciliation Recommendation: We recommend the District establish policies and procedures to ensure proper documentation of preparation and review of monthly Title IV reconciliations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions planned in response to finding: • The District will reconcile the institutional records with Pell funds monthly and maintain documentation and preparation of the reconciliation process • The Financial Aid Coordinator will be responsible for creating a SharePoint drive and maintaining the accuracy of the reconciliation process via SharePoint drive • Create a SharePoint so that when we have employee-related transitions, the newly assigned Financial Aid Coordinator will have access Responsible party: Financial Aid Coordinators and Workforce Finance Department Planned completion date for corrective action plan: April 30, 2026 Plan to monitor completion of corrective action plan: • The Financial Aid Coordinators and Workforce Finance Department will conduct a monthly review to confirm reconciliations are completed, documented, and properly approved. • Any issues identified during monthly reviews will be addressed promptly to ensure ongoing compliance.
The Educational Service Center will no longer work with this Subrecipient effectively upon issuance of this report.
The Educational Service Center will no longer work with this Subrecipient effectively upon issuance of this report.
Finding 2025-002 Material Weakness in Internal Control Over Special Tests and Provisions Compliance Requirements 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 He...
Finding 2025-002 Material Weakness in Internal Control Over Special Tests and Provisions Compliance Requirements 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 2025 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, 2025 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2026 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 June 30, 2026. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 800 East 55th Street, Chicago, IL 60615.
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding 2025-001 Material Weakness in Internal Control Over Reporting Compliance Requirements 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 Age...
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding 2025-001 Material Weakness in Internal Control Over Reporting Compliance Requirements 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 2025 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, 2025 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2026 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, Finance Manager, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. 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 compliance with timely submission of financial reports (FFR), Friend Health will implement a structured timeline that aligns with all regulatory deadlines and includes internal checkpoints to monitor progress. • The Organization has implemented a new Grants (Project) tracking module to better help with grants and contracts reporting and compliance. This module will track all deadline dates for all of the grants, including deadlines for submitting FFR’s. All grant-related year-end audit procedures have been transitioned to the Finance Manager who has experience with financial audits and compliance and reporting for City, State, and Federal grants. •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. The target date for full implementation of these corrective actions is June 30, 2026. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 800 East 55th Street, Chicago, IL 60615.
In the past month we have recruited a new Chief Administrative Officer with experience in financial management. By May we are scheduled to add a full charge accountant to our staff. With these staffing additions, we will be able to complete ongoing reviews of compliance with our cost allocation plan...
In the past month we have recruited a new Chief Administrative Officer with experience in financial management. By May we are scheduled to add a full charge accountant to our staff. With these staffing additions, we will be able to complete ongoing reviews of compliance with our cost allocation plan.
While all the costs reported to grantors were fully allowable per our contract, we continued to have some challenges in reflecting these costs in QuickBooks at the detailed level. We have implemented several accounting improvements that have addressed most of the differences between our cost reports...
While all the costs reported to grantors were fully allowable per our contract, we continued to have some challenges in reflecting these costs in QuickBooks at the detailed level. We have implemented several accounting improvements that have addressed most of the differences between our cost reports by contract and QuickBooks. We continue, however, to face challenges in allocating indirect costs (allowed by a contract) down to the level of individual contract accounts in QuickBooks. The second continuing challenge is allocation of certain fringe benefits such as employee savings match and contributions to Health Savings Accounts down to the contract level for staff who work on multiple contracts. In the past month we have added new staff with greater experience in accounting and are implementing new ongoing reviews that will assure that our QuickBooks information remains exactly in sync with our fiscal reports.
Management concurs with the finding. After the Fiscal Year 2024 monitoring finding last year, the Department developed a comprehensive certification for property owners to complete and a list of required files to be provided to the County on an annual basis. In 2025, Department staff confirmed with ...
Management concurs with the finding. After the Fiscal Year 2024 monitoring finding last year, the Department developed a comprehensive certification for property owners to complete and a list of required files to be provided to the County on an annual basis. In 2025, Department staff confirmed with the County’s HUD representative that the new monitoring documents and plan would satisfy the HUD’s monitoring requirements. Staff are providing technical assistance to the property owners, as preliminary records reviewed indicate all units are still maintained as affordable, but the owners’ provision of all documentation is still in progress. The physical inspections of the property exteriors in October 2025 indicated broadly that housing quality standards are still being maintained. The Department continues to seek out training for staff on HOME requirements and will continue efforts to update monitoring policies and procedures, as necessary, to address all current regulatory requirements. The Department’s multifamily monitoring for all projects in the HOME period of affordability for calendar years through 2024 will be completed prior to August 30, 2026. Although not due in Fiscal Year 2024-25, the Department is moving forward with monitoring for calendar year 2025, which is anticipated to be completed timely, prior to December 31, 2026. As part of the monitoring process, the Department will collect or create documents demonstrating a property’s annual or semi-annual (as relevant) compliance with HOME requirements, review for adherence to regulations, draft and issue a report of findings, and require owners of projects with deficiencies to prepare and submit a satisfactory corrective action plan. The Department will continue to follow up regularly with property owners until all corrective actions are implemented. Staff’s recommendation to facilitate ongoing, decades-long monitoring requirements include the creation of a master omnibus amendment to all existing property agreements to ensure concrete requirements for recordkeeping and monitoring are clearly outlined and accompanied by explicit deadlines. This amendment will be pursued as time permits and after lessons learned from current monitoring activities are integrated into the monitoring process. Anticipated Completion Date August 2026 Contact Information of Responsible Official Name: Augustine Ramirez Title: Division Manager, DPWP Community Development Division Phone: 559-600-4266
Finding #SA2025-002 Unallowable Expenditures Charged to the Grant Assistance Listing Number: 20.507, 20.526 Assistance Listing Title: COVID-19 – Federal Transit Formula Grants (Urbanized Area Formula Program) – Federal Transit Cluster Name of Federal Agency: Department of Transportation Federal Awar...
Finding #SA2025-002 Unallowable Expenditures Charged to the Grant Assistance Listing Number: 20.507, 20.526 Assistance Listing Title: COVID-19 – Federal Transit Formula Grants (Urbanized Area Formula Program) – Federal Transit Cluster Name of Federal Agency: Department of Transportation Federal Award Identification Number: CA-2022-083-00, 2020-206, 2020-212 • Name(s) of the contact person: Melissa Munoz, Interim Assistant Finance Director • Corrective Action Plan: The City will develop procedures for grant management, accounting and reporting to ensure that only allowable costs are claimed. • Anticipated Completion Date: 06/30/2026
2025-001: Reporting – Early Steps Grantor: Department of Education (ED) Program Title: Special Education Grants for Infants & Families Award Name: Early Steps Award Numbers: H181A230099 Assistance Listing Titles: Special Education – Grants for Infants & Families with Disabilities Assistance Listing ...
2025-001: Reporting – Early Steps Grantor: Department of Education (ED) Program Title: Special Education Grants for Infants & Families Award Name: Early Steps Award Numbers: H181A230099 Assistance Listing Titles: Special Education – Grants for Infants & Families with Disabilities Assistance Listing Number: 84.181 (Federal Portion), 64.022 (State of Florida Portion) Award Years: July 1, 2024 – June 30, 2025 Passthrough Entities: Department of Health (Federal Portion), The State of Florida Department of Health (State of Florida Portion) Management agrees with the finding and recommendation. Management acknowledges the delays in report submissions identified in the finding. The exceptions were primarily due to operational disruptions caused by Hurricane Helene, an extension request that was not formally documented, and outdated agency contact information that resulted in misdirected report submissions. While certain factors were outside of normal operational control, management recognizes the importance of timely reporting and maintaining complete and accurate documentation to support compliance with program requirements. To address these issues and strengthen internal controls, management has implemented the following corrective actions: • Established a requirement to retain written documentation for all extension requests, including evidence of approval from the granting agency. • Enhanced tracking procedures by incorporating internal due dates within reporting schedules to better monitor and ensure timely submission of required reports. These actions are designed to improve the timeliness and accuracy of reporting and to ensure a complete audit trail for all required submissions. Management will continue to monitor the effectiveness of these controls to ensure ongoing compliance and prevent recurrence of similar issues. Management will remediate this finding by June 30, 2026.
Garfield County School District No. 16 respectfully submits the following corrective action plan for the year ended June 30, 2025. Finding 2025-001 Reporting Significant Deficiency in Internal Control over Compliance and Other Non-Compliance Corrective Action: The District agrees with the finding re...
Garfield County School District No. 16 respectfully submits the following corrective action plan for the year ended June 30, 2025. Finding 2025-001 Reporting Significant Deficiency in Internal Control over Compliance and Other Non-Compliance Corrective Action: The District agrees with the finding related to insufficient supporting documentation for the National School Lunch Program reimbursement claims, as it related to sack lunches/field meals. Personnel Responsible for Corrective Action: Jody Williams, Food Service Director Anticipated Completion Date: The District has corrected this issue as of the date of this report, and now requires formal written requests for all sack lunches/field meals, to ensure counts are properly documented.
15.047 Indian Education Facilities, Operations, and Maintenance – Assistance Listing No. Recommendation: To implement a stronger system of review for ensuring that all changes in employee payroll are properly implemented and approved. Explanation of disagreement with audit finding: There is no disag...
15.047 Indian Education Facilities, Operations, and Maintenance – Assistance Listing No. Recommendation: To implement a stronger system of review for ensuring that all changes in employee payroll are properly implemented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Human Resources (HR) is working with Finance to process retroactive compensation for the full underpaid amount owed. Associated DRS contributions will also be reviewed and corrected to ensure full compliance. Moving forward, HR will implement an enhanced verification control at the beginning of each fiscal year. This includes documented confirmation of pay accuracy for a minimum of two employees per department following salary schedule implementation and prior to the first payroll. Ideally, this control will be performed jointly by HR and Finance to ensure segregation of duties and consistency. Name(s) of the contact person(s) responsible for corrective action: Beth Wilde, Director of Human Resources Planned completion date for corrective action plan: July 1, 2026
FINDING 2025-002 USDA LOAN COVENANTS COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and EHR system in May 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearin...
FINDING 2025-002 USDA LOAN COVENANTS COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and EHR system in May 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the Hospital offline from processing claims. These two events had a negative and material impact on the Hospital’s cash collections over the last two years resulting in the Hospital not having the required 90 days of cash on hand. The Hospital did receive a waiver from the USDA regarding not meeting this loan covenant for fiscal year 2025. Views of responsible officials and planned corrective actions The Hospital has made several changes to its system since the initial implementation and has contracted with a third party vendor to make improvements in its billing and collection processes. These changes are expected to result in cash collection improvements. Additionally, the Centers for Medicare and Medicaid Services (CMS) approved the State of Nebraska’s preprint and provider assessment waiver that governs Nebraska’s Medicaid Directed Payment Program (Program). CMS’ approval of the Program is for the period July 1, 2024 through December 31, 2024 and January 1, 2025 to December 31, 2025 only, with future years subject to an annual approval by CMS. These additional funds are also expected to significantly improve the Hospital’s days of cash on hand by the end of fiscal year 2026. Hospital management notified its USDA representatives and received a waiver from the 90 days of cash on hand for the period ended June 30, 2025. Anticipated completion date Ongoing
Corrective Action Plan: The organization will continue with its ongoing implementation of several measures to ensure accuracy and compliance in the sliding fee process. Monthly audits will continue to be conducted to review all sliding fee application forms from the previous month for accuracy and v...
Corrective Action Plan: The organization will continue with its ongoing implementation of several measures to ensure accuracy and compliance in the sliding fee process. Monthly audits will continue to be conducted to review all sliding fee application forms from the previous month for accuracy and verifying information in NextGen. Skills assessments will continue to be conducted in January and July to identify staff needing refresher training. A sliding fee wage training video has been added to Relias and will be required for all staff involved in the process, providing guidance on wage calculation. This training will be distributed twice a year. Additionally, sliding fee monthly audit results will be reported quarterly at QA/QI meetings. To enhance accountability, the organization has implemented an expiration policy for applications lacking supporting documentation within 30 days. The system will automatically expire these applications on day 31, prompting staff to have the patient reapply. Patients who fail to provide the required documentation within the timeframe will receive an invoice or statement for all services rendered during the 30-day period. Estimated completion date: September 30, 2026 Contact person: Jessica Dana, Vice President of Strategy
Finding 2025-001 Condition During our audit, 1 out of 3 employees selected for testing received a bonus payment for achieving first year enrollment goals. The College then determined 2 employees received such bonuses and additional testing confirmed a total of 2 out of 27 employees who were involved...
Finding 2025-001 Condition During our audit, 1 out of 3 employees selected for testing received a bonus payment for achieving first year enrollment goals. The College then determined 2 employees received such bonuses and additional testing confirmed a total of 2 out of 27 employees who were involved in the College's admissions/recruiting, financial aid and registrar offices received bonuses based on their contributions towards enrollment performance. These bonuses were paid from internal College funds and not from Title IV funds. Corrective Action Plan Corrective Action Planned: The college implemented a policy on incentive pay citing the restrictions and banning incentive pay for specific job duties. The policy and a standard form for awarding additional compensation have been reviewed and approved by senior leadership and posted to the college’s human resources website. Name(s) of Contact Person(s) Responsible for Corrective Action: Amanda Stahl, Vice President for Finance and Ann Eckert, Assistant Vice President for Human Resources will be responsible for ensuring adherence to the policy and review of any awarding of additional compensation. Anticipated Completion Date: The policy and forms were approved and completed September 30, 2025.
2025-001 ELIGIBILITY Program: Child Nutrition Cluster CFDA Number: 10.533, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Type of Finding: Noncompliance, significant deficiency in internal control Compl...
2025-001 ELIGIBILITY Program: Child Nutrition Cluster CFDA Number: 10.533, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Type of Finding: Noncompliance, significant deficiency in internal control Compliance Requirement: E. Eligibility Criteria: Federal regulations require participating districts to determine student eligibility for free, reduced price, and paid meals based on household income and household size thresholds established annually by the U.S. Department of Agriculture. Applications must be reviewed and approved using the current income eligibility guidelines and appropriate calculation methods to ensure correct benefit levels. Condition: During testing of 25 student meal applications, we noted 1 instance where the District incorrectly calculated household income relative to household size when determining eligibility status. In these cases, students were approved for free price meals when the income calculations supported reduced meal status. Cause: The District did not have sufficient review controls in place to ensure that eligibility determinations were recalculated or independently verified prior to approval. Effect: As a result of the errors, certain students received free meal benefits for which they were not eligible. This may have resulted in improper program reimbursement claims and indicates that the District’s controls over eligibility determinations were not operating effectively. Questioned Costs: The projected questioned costs related to these errors are not expected to be material; however, the District may have received reimbursement at the free price rate rather than the reduced rate for affected meals. Corrective Action: The District will review their meal application process and implement a more stringent review to ensure eligibility criteria are met based on household income. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Erika Aguallo, Business Manager
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