Corrective Action Plans

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After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in Decem...
After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in December 2025.
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit ...
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will work with program managers to improve eligibility verification documentation. Name of the contact person responsible for corrective action: Heather Goodwin Planned completion date for corrective action plan: December 31, 2026
Management agrees with the recommendations. During 2025, DVCH’s front desk staff started to assume more responsibility for conducting the sliding fee categorization. This additional staff had training and is gaining experience. Management will ensure training, monitoring, auditing, and supervision i...
Management agrees with the recommendations. During 2025, DVCH’s front desk staff started to assume more responsibility for conducting the sliding fee categorization. This additional staff had training and is gaining experience. Management will ensure training, monitoring, auditing, and supervision is adequate to ensure registration properly documents the signed sliding fee attestation form. DVCH expects to adopt a software solution for sliding fee categorization in 2026. The software solution will make common errors less common by automating several manual processes. If the Health Resources and Services Administration has questions regarding this plan, please call Ryan Taylor, Chief Financial Officer, at taylorr@dvch or 267-240-2578.
Name of contact person: Melissa Labra, Income Maintenance Administrator II Caseworkers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Casework...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Caseworkers will receive additional training on countable/non-countable resources. Workers will be reminded of the procedures and policies that should be followed at time of application and recertification processes. Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Workers will be retrained on NCFAST evidence for resources to ensure procedures are being followed for evidence on dashboard to match the supporting documentation used as verifications. Workers will be retrained on determining who to count in the needs unit and adequate case file documentation. Workers will be retrained on the proper use of Medicaid Forced Eligibility. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Proposed Completion Date: August 31, 2026
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct income evidence into NCFAST. Caseworkers will receive training on determining the correct base period to use for income calculations Cas...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct income evidence into NCFAST. Caseworkers will receive training on determining the correct base period to use for income calculations Caseworkers will receive training on the work number (TWN) in NCFAST learning gateway. Caseworkers will receive training on income and budgeting policy (MA 3300). Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly, including income calculations Proposed Completion Date: August 31, 2026
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on completing complete and thorough case documentation. Caseworkers will receive additional training on inputting the correct evidence into NCFAST, including inc...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on completing complete and thorough case documentation. Caseworkers will receive additional training on inputting the correct evidence into NCFAST, including income evidence. Supervisors will review cases to verify that evidence in NC FAST and supporting documentation match. Supervisors will conduct second party reviews on applications and recertification’s to determine that proper policies and procedures are being followed. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 31, 2026
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers will receive additional training on obtaining adequate verifications for income. Caseworkers will receive additional training on completing complete and thorough case documentation. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 30, 2026
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files t...
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files tested: • In one patient file selected for testing, the sliding fee discount applied was incorrect due to the patient’s income not being entered correctly in Epic, resulting in an inaccurate FPL calculation and associated discount classification. • In one patient file selected for testing, based on support provided and the SFDS, an incorrect discount class was applied, and the County was not able to provide documentation demonstrating how annual income/household size supported the applied discount classification. Hennepin County’s Corrective Action Planned in Response to Finding: Develop a required form for all case aides to use and uniformly determine “annual income”. The EPIC Financial Assistance Module (FAM) recently implemented will maintain record of patient financial calculations / conversations and will include upload of the financial income form. Determination of the proper patient discount is automated in FAM and will reduce chance of incorrect rate setting. Hennepin County Employee Responsible for the CAP: Baye D Diouf, Chief Financial Officer Planned Completion Date for CAP: September 30, 2026
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP progr...
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP program period each year.
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization...
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations re...
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations regarding ethical behavior through training and communications. HealthXP proactively reports and investigates allegations of fraud and raises awareness of the actions to be taken when fraud is suspected. The HealthXP Global Internal Audit and Investigations team shares lessons learned from its work. Given the challenging operating environments in which HealthXP implements its programs, fraud remains an ongoing risk that HealthXP actively monitors, investigates, and mitigates.
Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into inte...
Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into interest-bearing accounts. Also, establish a process to track interest earned on Federal advances and remit annually any interest above the $500 de minimis threshold to the federal agency per §200.305(b)(11), retaining records of calculation and remittance.
Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appro...
Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appropriate PSI and EGPAF staff and reinforced through training to ensure adequate attention and clear guidance on the allowability of trailing costs and the unallowability of newly incurred costs.
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporti...
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporting documentation (General Ledger and invoices) for accuracy before the report is submitted to the granting agency.•Responsible Party: Executive Director and Board Finance Committee. Anticipated Completion Date: February 28, 2026.
The Authority will establish controls to ensure all certifications are completed timely and in accordance with requirements.
The Authority will establish controls to ensure all certifications are completed timely and in accordance with requirements.
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management ...
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management review. In addition, the Authority should train relevant personnel on these policies and perform ongoing monitoring to confirm that federal expenditures are reviewed and documented in accordance with applicable grant requirements. Management’s Response: Management acknowledges the recommendation. The Authority will evaluate its existing processes and controls over the use of federal funds and consider whether additional written guidance and/or enhancements to current procedures are warranted to address, as applicable, cost allowability, procurement requirements, approval responsibilities, documentation and record retention, subrecipient or vendor oversight, reimbursement request preparation and review, and periodic management review of federal expenditures. Based on the results of this evaluation, the Authority will communicate any clarifications, reminders, and/or targeted training to relevant personnel involved in administering, approving, recording, or requesting reimbursement for federal expenditures, as deemed necessary. Management will also consider whether additional monitoring activities are warranted to help confirm that federal expenditures are reviewed, approved, and supported by appropriate documentation in accordance with applicable grant requirements.
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S Department of Health and Human Services 2025-001 Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: We recommend that there is an appropriate reviewer of the WIMCR cost report and CLTS annual reconciliation. Explanation of disagreement with au...
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S Department of Health and Human Services 2025-001 Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: We recommend that there is an appropriate reviewer of the WIMCR cost report and CLTS annual reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will evaluate their current processes and procedures during staffing transitions in fiscal year 2025 to ensure that proper review of the WIMCR cost report and the CLTS annual reconciliation. Name(s) of the contact person(s) responsible for corrective action: Hollie Viestenz and Tim Marzu Planned completion date for corrective action plan: December 31, 2026 If the State of Wisconsin has questions regarding this plan, please call Hollie Viestenz at (715) 732-7422.
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsib...
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Planned 1. The Hospital will establish an annual audit readiness timeline working backward from the Uniform Guidance submission deadline (the earlier of thirty (30) calendar days after receipt of the auditors’ reports or nine months after the end of the audit period, June 30). The timeline will include target dates for the completion of year-end closing procedures, the delivery of auditor-requested schedules and supporting documentation, audit fieldwork, review of the draft report, and submission of the reporting package and Data Collection Form to the Federal Audit Clearinghouse in advance of the deadline. 2. Monthly closing discipline will be maintained throughout the fiscal year so that year-end balances, account reconciliations (including patient accounts receivable aging, the allowance for credit losses, and grants receivable), and audit support schedules are substantially complete at year end and available for timely delivery to the auditors. 3. The Chief Financial Officer will monitor the status of the audit timeline monthly beginning in October of each fiscal year, and any delay against the established milestones will require a documented recovery plan to return the process to schedule. 4. The Single Audit Reporting Package and Data Collection Form for the year ended September 30, 2025 will be submitted to the Federal Audit Clearinghouse immediately upon issuance of the final audit report. Anticipated Completion Date October 31, 2026
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J....
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Taken and Planned 1. Resolution of the two identified cases. The Hospital reviewed and resolved the two patient accounts identified in the audit sample in which an incorrect sliding fee discount percentage was applied: • In the first case, the discount applied resulted in a charge to the patient below the amount that corresponded under the correct Federal Poverty Guidelines discount tier, and a lower amount was collected from the patient. Management evaluated the account and determined not to retroactively bill the patient for the remaining difference, consistent with the Hospital’s mission and its policy of not creating barriers to care for patients eligible under the Sliding Fee Discount Program. • In the second case, the Hospital billed and collected from the patient an amount higher than the amount that corresponded under the correct discount tier. This case was resolved and the amount collected in excess of the correctly discounted amount was returned to the patient by check no. 95274, issued on May 29, 2026. Documentation of the refund is retained in the patient’s account file. 2. Questioned cost. The known questioned cost of $245.97 has been repaid and offset by the Hospital. Supporting documentation of the resolution is available for review by the awarding agency. 3. Current Federal Poverty Guidelines implementation. The Sliding Fee Discount Schedule will be updated to the current Federal Poverty Guidelines (FPG) issued annually by HHS, and a standing procedure will be established requiring that the updated schedule be approved and incorporated into the Hospital’s billing system (eClinicalWorks) within thirty (30) days of the annual publication of the FPG. 4. Review of sliding fee determinations. The review process over sliding fee discount determinations, which had previously been performed by the Billing Department and was later delegated to the information management staff, has been returned to the Billing Department to ensure that discounts are properly applied to patients in accordance with the Sliding Fee Discount Program policies and the updated fee schedule. 5. Strengthened internal controls. A secondary review control will be implemented under which a quarterly sample of new and renewed SFDP eligibility determinations will be re-verified by the Billing Department against the current FPG schedule, income documentation, and household size, with the results documented in a monitoring log subject to review by the Chief Financial Officer. 6. Training. Formal training on the SFDP policy, the current FPG schedule, and the related documentation requirements will be provided to all registration, billing, and eligibility staff, with attendance documented. Refresher training will be provided annually upon each FPG update. Anticipated Completion Date Items 1 and 2 – Completed. Items 3 through 6 – October 31, 2026.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF THE TREASURY, COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS (CSLFRF) – FEDERAL ALN 21.027 AND U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT, ECONOMIC DEVELOPMENT INITIATIVE, COMMUNITY PROJECT FUNDING, AND...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF THE TREASURY, COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS (CSLFRF) – FEDERAL ALN 21.027 AND U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT, ECONOMIC DEVELOPMENT INITIATIVE, COMMUNITY PROJECT FUNDING, AND MISCELLANEOUS GRANTS – FEDERAL ALN 14.251 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires City of Farmington, Minnesota (the City) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the Economic Development Initiative and CSLFRF federal programs. During our audit, we noted the City did not have sufficient controls in place within these programs to ensure compliance with federal requirements related to assuring that the City was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City performed the required suspension and debarment verifications; however, documentation was not retained for two of the three vendors tested. To strengthen internal controls going forward, the City has implemented an updated procedure requiring staff to consistently retain documentation of suspension/debarment checks at the time of procurement for all federally funded contracts. This includes either (1) a SAM.gov screen print; (2) a copy of the contractor’s certification; or (3) a retained record of the method used. The Finance Director has reinforced this requirement with the responsible staff to ensure consistent and complete documentation going forward. Official Responsible – Kim Sommerland, Finance Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The City agrees documentation was not retained for two vendors. Plan to Monitor – The Finance Director will oversee compliance with the updated procedures and will conduct periodic spot checks to ensure documentation is consistently retained for all federally funded procurements.
Finding Number: 2025-001 Finding Title: Equipment and Real Property Management Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Jenn Moses, Manager of Planning and Community Development Corrective Action Planned: • Conduc...
Finding Number: 2025-001 Finding Title: Equipment and Real Property Management Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Jenn Moses, Manager of Planning and Community Development Corrective Action Planned: • Conduct a training for community development staff on federal regulations related to equipment and real property management • Assign specific employees oversight of equipment inventory • Coordinate with the finance department to ensure all CDBG assets are appropriately categorized within inventory • Implement monitoring protocol for yearly audit of the inventory Anticipated Completion Date: November 30, 2026
2025-006: STUDENT MEAL APPLICATIONS Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Non...
2025-006: STUDENT MEAL APPLICATIONS Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: E. Eligibility Condition: During our testing of eligibility determinations under the Child Nutrition Cluster, we selected 40 student meal applications for review. Of the 40 applications tested, two applications were incorrectly classified based on the information provided on the applications. Specifically, one application was approved as free when it should have been approved as reduced, and one application was approved as reduced when it should have been approved as paid based on applicable eligibility guidelines. Action planned in response to finding: The District will ensure nutrition applications are reviewed to determine they meet the appropriate classification criteria. In addition, applications will be reviewed and approved by someone other than the initial individual that is recording the classification type. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Edward Dickie, Business Manager.
Finding Documentation was not retained to evidence management review and approval of PR-29 reports prior to submission. Corrective Action Planned The process was enhanced for 2026 to include documented review and approval of quarterly PR-29 reporting, by the Housing Finance Manager, prior to submiss...
Finding Documentation was not retained to evidence management review and approval of PR-29 reports prior to submission. Corrective Action Planned The process was enhanced for 2026 to include documented review and approval of quarterly PR-29 reporting, by the Housing Finance Manager, prior to submission. Contact Person Nicole Babcock Anticipated Completion Date Implemented June 2026; ongoing monitoring thereafter.
2025-005: REPORTING Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Othe...
2025-005: REPORTING Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: L. Reporting Condition/Context: During our review of meals claims submitted for reimbursement, we noted variances between the District’s meal counts and what was submitted to the Arizona Department of Education. For four months tested, meals claims were net under-reported by 10,403 lunch and breakfast meals, which calculated to $3,616.29. Additionally, for three of 4 months tested, the District did not maintain any documentation to support that the claims were reviewed by a second person. Action planned in response to finding: The District will ensure a second employee verifies and approves all NSLP Claim forms to ensure the claims submitted are accurate and complete prior to submission. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Jim Serbin, CFO.
Finding 2025-001 – Noncompliance – Reporting (Repeat) Recommendation: The auditors recommend the Organization implement procedures to ensure the data collection form is submitted within the earlier of 30 calendar days of the audit report being issues, or 9 months after the end of the audit period. A...
Finding 2025-001 – Noncompliance – Reporting (Repeat) Recommendation: The auditors recommend the Organization implement procedures to ensure the data collection form is submitted within the earlier of 30 calendar days of the audit report being issues, or 9 months after the end of the audit period. Actions Taken or Planned: Management understands the data collection form was not submitted within 9 months of June 30th year end. Procedures will be implemented to make sure the audit is completed prior to the 9 month deadline. Data collection forms will then be uploaded to the Federal Audit Clearinghouse prior to the 9 month deadline or within 30 days of the audit report being issued. Name of Contact Person: Larissa Dickens, Director of Finance Estimated Date of Completion: June 30, 2026
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