Corrective Action Plans

Finding 520298 (2024-001)

Significant Deficiency 2024

CA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

The District and its Financial Aid department will continue to review and enhance the workflow and procedures of Return to Title IV. The goal of these efforts has been to meet the compliance requirements of Return to Title IV. The District has developed a schedule with specific dates per term for wh...

The District and its Financial Aid department will continue to review and enhance the workflow and procedures of Return to Title IV. The goal of these efforts has been to meet the compliance requirements of Return to Title IV. The District has developed a schedule with specific dates per term for when calculations will be completed, when requests will be made to Accounting to return the District portion of funds within 45 days, and provide ample timelines that can ensure funds get returned within compliance. The District has included the various department areas and staff that are involved in the process to ensure the schedule is consistent and that the funds are returned in the appropriate time frame. The Financial Aid department will continue to meliorate the task of the Return to Title IV calculations. This task is a work function of the Financial Aid Coordinator position. While staff has been trained to perform this function, the District is currently in recruitment to fill the Financial Aid Coordinator position. While the Coordinator will be expected to perform the calculations, they will be submitted to the Director of Financial Aid for review and to ensure accuracy.

View Audit 340029

Finding 520293 (2024-003)

Significant Deficiency 2024

T.a. Lawson State Community College

AL

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Management's Response: The College will strengthen its policies and procedures surrounding payroll grant disbursements to ensure expenses are properly approved and allowable under the specific grant budget. Management will ensure that budgets are amended when changes in pay rates occur during the ...

Management's Response: The College will strengthen its policies and procedures surrounding payroll grant disbursements to ensure expenses are properly approved and allowable under the specific grant budget. Management will ensure that budgets are amended when changes in pay rates occur during the grant award periods. Anticipated Completion Date: February 28, 2025

View Audit 340025 Questioned Costs: $1

Finding 520291 (2024-002)

Significant Deficiency 2024

T.a. Lawson State Community College

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management's Response: The College will strengthen its policies and procedures surrounding non-payroll grant disbursements to ensure disbursements are approved, allowable, and calculations supported. Management will review budgets on a monthly basis to ensure expenses do not exceed the budget. M...

Management's Response: The College will strengthen its policies and procedures surrounding non-payroll grant disbursements to ensure disbursements are approved, allowable, and calculations supported. Management will review budgets on a monthly basis to ensure expenses do not exceed the budget. Management will review indirect cost calculations to ensure they are calculated at the correct percentages. Management will review invoices three months past year end to ensure the proper accrual of expenses. Anticipated Completion Date: February 28, 2025

View Audit 340025 Questioned Costs: $1

Finding 520287 (2024-001)

Significant Deficiency 2024

Calvin University

MI

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Condition: The University does not have controls in place for review of Return of Title IV calculation. Planned Corrective Action: All R2T4 calculations will be reviewed by a second individual within the Calvin Financial Aid Office. Calculations will not become final until both individuals agree wit...

Condition: The University does not have controls in place for review of Return of Title IV calculation. Planned Corrective Action: All R2T4 calculations will be reviewed by a second individual within the Calvin Financial Aid Office. Calculations will not become final until both individuals agree with the specifics of each calculation. Contact person responsible for corrective action: James Koeman, Director of Financial Aid Anticipated Completion Date: Already completed as of the 24FA term.

View Audit 340021

Finding 520252 (2024-001)

Significant Deficiency 2024

Family Health Services of Erie County

OH

Eligibility Significant Deficiency Program Income

Finding Number: 2024-001 Anticipated Completion Date: January 31, 2025 Responsible Contact Person: David Tatro, CEO Planned Corrective Action: The Organization provided approximately 2,300 self-pay encounters to be audited for the year ended May 31, 2024. 40 encounters were identified for compliance...

Finding Number: 2024-001 Anticipated Completion Date: January 31, 2025 Responsible Contact Person: David Tatro, CEO Planned Corrective Action: The Organization provided approximately 2,300 self-pay encounters to be audited for the year ended May 31, 2024. 40 encounters were identified for compliance testing related to the sliding fee. Three self-pay accounts were identified with issues which resulted in this finding. The issues related to patients receiving an improper discount rate. This issue will be resolved as of January 31, 2025 by reviewing all sliding fee scale applications for accuracy. The Organization will continue to monitor the sliding fee scale amounts applied to ensure ongoing compliance with the requirements. The Organization will review five sliding fee scale applications each week to ensure eligibility determination, billing and collection follows the Sliding Fee Discount Program. This will go through May 2025 with a reassessment at that point, based on the results of the internal review.

View Audit 339892

Finding 520237 (2024-013)

Significant Deficiency 2024

City of Albuquerque

NM

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment

The City concurs with the finding. The CDBG contract check list has been updated to include the FFATA reporting requirement. The Fiscal CDBG Policies and procedures have been modified to include a section on FFATA reporting to be completed with the time frame set forth in the FF AT A requirements.

View Audit 339863

Finding 520236 (2024-012)

Significant Deficiency 2024

City of Albuquerque

NM

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

The City concurs with the finding. The APD Grant Administrator will establish a process to ensure that all programmatic reports are submitted on time by creating a spreadsheet to track the due dates for each programmatic report. Once the reports are submitted, it will be the responsibility of the Gr...

The City concurs with the finding. The APD Grant Administrator will establish a process to ensure that all programmatic reports are submitted on time by creating a spreadsheet to track the due dates for each programmatic report. Once the reports are submitted, it will be the responsibility of the Grant Coordinator to record the submission date. If a report is submitted late, the Grant Coordinator must contact the grantor by the end of the day to explain the reason for the delay.

View Audit 339863

Finding 520235 (2024-011)

Significant Deficiency 2024

City of Albuquerque

NM

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.403

The City concurs with the finding. Albuquerque Police Department (APD) Grant Administrator will meet with the City Grant Administrator to review and prepare the necessary payroll corrections, ensuring that all payroll charges allocated to the grant are accurate. The APD Grant Administrator will be r...

The City concurs with the finding. Albuquerque Police Department (APD) Grant Administrator will meet with the City Grant Administrator to review and prepare the necessary payroll corrections, ensuring that all payroll charges allocated to the grant are accurate. The APD Grant Administrator will be responsible for submitting correcting payroll reclassifications to the City's Grants Management Section for review, entry and approval no later than January 31, 2025. APD will work directly with the City's Grants Management Section to establish new reconciliation, reclassification and validation processes to ensure that only eligible officers and pay types are charged to the grant.

View Audit 339863

Finding 520234 (2024-010)

Significant Deficiency 2024

City of Albuquerque

NM

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.511

The City concurs with the finding. Transit Department staff is in the process of developing a policy establishing internal controls over timekeeping and is near finalizing the policy. Once finalized, the policy will be reviewed with appropriate parties. Further, the Transit Department is exploring t...

The City concurs with the finding. Transit Department staff is in the process of developing a policy establishing internal controls over timekeeping and is near finalizing the policy. Once finalized, the policy will be reviewed with appropriate parties. Further, the Transit Department is exploring the purchase and implementation of additional software to assist with enacting these controls.

View Audit 339863

Finding 520233 (2024-009)

Significant Deficiency 2024

City of Albuquerque

NM

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

The City concurs with the finding. The City's Grant Administrator will work with the Department of Health, Housing and Homeless and the Department of Municipal Development to adequately document the comparison of capital expenditure options and demonstrate the superiority of the chosen capital proje...

The City concurs with the finding. The City's Grant Administrator will work with the Department of Health, Housing and Homeless and the Department of Municipal Development to adequately document the comparison of capital expenditure options and demonstrate the superiority of the chosen capital project in the final written justifications.

View Audit 339863

Finding 520161 (2024-002)

Significant Deficiency 2024

Tri-City Healthcare District

CA

HUD Housing Programs Cash Management Reporting

Finding 2024-002: Reporting – Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Corrective Action Planned: The District agrees with the findings and management has implemented a corrective action plan to ensure the required reports are filed timely. Starting Ja...

Finding 2024-002: Reporting – Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Corrective Action Planned: The District agrees with the findings and management has implemented a corrective action plan to ensure the required reports are filed timely. Starting January 2024, all financial reports were filed on time. Person Responsible for Corrective Action: Anh Nguyen, Controller Anticipated Completion Date: June 30, 2025

View Audit 339746

Finding 520099 (2024-001)

Significant Deficiency 2024

Halifax County, North Carolina

NC

Allowable Costs / Cost Principles Reporting Cash Management

2024-001 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Contact Person Responsible for the Corrective Action Plan: Mary W. Duncan, Finance Director Corrective Action Plan: We have discussed the finding and are currently implementing control...

2024-001 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Contact Person Responsible for the Corrective Action Plan: Mary W. Duncan, Finance Director Corrective Action Plan: We have discussed the finding and are currently implementing controls to ensure the timesheets are appropriately reviewed to match with daysheets. Anticipated Completion Date: June 30, 2025

View Audit 339672

Finding 520070 (2024-001)

Significant Deficiency 2024

Wilson County, North Carolina

NC

Special Tests & Provisions Significant Deficiency

Corrective Action Plan CY Findings: 2024 -001 U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services, Division of Social Services Program Name: DSS Crosscutting (State) Supplemental Nutrition Assistance Program AL#10.561 CY Finding 2024-001 Signi...

Corrective Action Plan CY Findings: 2024 -001 U.S. Department of Health and Human Services Passed through the N.C. Department of Health and Human Services, Division of Social Services Program Name: DSS Crosscutting (State) Supplemental Nutrition Assistance Program AL#10.561 CY Finding 2024-001 Significant Deficiency over Internal Controls Name of Contact Person: Melissa McDaniels, SIU Supervisor Corrective Action/Management’s Response: Our prior process for completing the DSS-1682 was not fully aligned with federal policy and guidelines. During the audit a DSS-1682 form with a February date of discovery entered into NC Fast was found unsigned by supervisor. This form was reviewed and approved by the new supervisor in July when brought to her attention. Prior to completing the approval, clarity was sought from our state partner. Guidance was provided to SIU Supervisor (Melissa McDaniels) concerning processing the DSS-1682 accurately according to policy 800.06 D.7(Katie White 7/19/24). Program staff (SIU) was retrained on the DSS-1682. A reminder of state policy and the proper way to complete DSS-1682 was sent to staff on 8/9/2024 by SIU Supervisor Melissa McDaniels. These measures are in place to prevent future errors with the DSS-1682 form. Prior supervisors of SIU (Jessica Murphy and Kathy Alston) were asked to provide training to the new supervisor and Business Officer to ensure all agency practices align with DSS policy. All SIU dates of Discovery are being reviewed and verified by staff when completing 2nd reviews. Proposed Completion Date: 8/9/2024

View Audit 339573

Finding 520035 (2024-002)

Significant Deficiency 2024

Stanford Youth Solutions

CA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

The Payroll Internal Control issue was procedural and did not impact the financials or cost allocation. The Organization will address and resolve this procedural issue through a review and retraining of procedures, an audit of records, and ongoing monitoring. ...

The Payroll Internal Control issue was procedural and did not impact the financials or cost allocation. The Organization will address and resolve this procedural issue through a review and retraining of procedures, an audit of records, and ongoing monitoring. 1. Update Procedures, Documentation, and Retrain All Payroll staff to Protocols: The Payroll 2024/2025 Internal Controls memo and Payroll Desk Manual will be revised to clearly detail the step-by-step procedures that Payroll personnel must follow for staff timecard submissions. The documentation includes the approval process by managers or their delegates, handling of missing approvals, and the review process conducted by Finance management. The documentation will also emphasize the procedural component and collaboration with human resources regarding the corrective actions required for managers who are not compliant with the procedures. These updates will ensure a smooth completion of the bi-monthly payroll cycle and facilitate monthly reviews. All payroll staff and the controller will undergo retraining in this process. New payroll staff will receive training in accordance with these expectations. Planned date of completion: 1/31/2025 2. Timecard Audit: Payroll will audit timecards for the period from July 1, 2024, to November 30, 2024. The audit aims to identify timecards that require approval from both employees and management. Any timecards that need approval will be addressed using the backup documentation required by the agency's internal control procedures. Planned date of completion: 1/31/2025 3. Ongoing Monitoring Plan: After each pay period, an audit report will be generated that includes the details of timecards, specifically identifying those paid through UKG that are missing approvals. The analyst will ensure that documentation is obtained from the employee's manager, confirming approval of staff time for each identified missing approval. These reports will be reviewed during the Payroll month-end cycle. Planned date of completion: bi-monthly payroll closes on the 10th and 25th of each month, respectively.

View Audit 339523

Finding 520000 (2024-001)

Significant Deficiency 2024

Lifelong Medical Care

CA

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

12/11/2024 LifeLong Medical Care Corrective Action Plan For the year ended June 30, 2024 2024-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Brent Copen, CFO Corrective Action: LifeLong Medical Care will: - Immediately retrain s...

12/11/2024 LifeLong Medical Care Corrective Action Plan For the year ended June 30, 2024 2024-001 Special Tests and Provisions - Significant deficiency in Internal Control over Compliance Name of Contact Person: Brent Copen, CFO Corrective Action: LifeLong Medical Care will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions. Proposed Completion Date: June 30, 2025

View Audit 339437

Finding 519969 (2024-001)

Significant Deficiency 2024

Peckham Inc. and Subsidiaries

MI

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.430

Action to be Taken: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future. This issue was isolated to a specific payroll, where a report did not function as intended. No issues were detected with either prior or future payrolls. However,...

Action to be Taken: The Organization concurs with the facts of this finding and is implementing procedures to prevent this in the future. This issue was isolated to a specific payroll, where a report did not function as intended. No issues were detected with either prior or future payrolls. However, we have implemented the additional step of checking these reports to timesheets to ensure there are no discrepancies.

View Audit 339414 Questioned Costs: $1

Finding 519870 (2024-003)

Significant Deficiency 2024

Alexander County

NC

Questioned Costs Special Tests & Provisions Student Financial Aid

Name of Contact Person: Jennifer Herman, Finance Director Corrective Action: 1. The Finance Office will no longer make corrections on employee mileage and meal reimbursement forms submitted by County departments. Finance Office staff will return incorrect forms for departmental personnel to make...

Name of Contact Person: Jennifer Herman, Finance Director Corrective Action: 1. The Finance Office will no longer make corrections on employee mileage and meal reimbursement forms submitted by County departments. Finance Office staff will return incorrect forms for departmental personnel to make corrections and resubmit the reimbursement form. Proposed Completion Date: This plan has been implemented since October 1, 2024. 2. The County will update its travel policy and require County department heads to be responsible for the use of approved rates on employee travel reimbursement forms. Proposed Completion Date: January 1, 2025.

View Audit 339174 Questioned Costs: $1

Finding 519866 (2024-002)

Significant Deficiency 2024

Alexander County

NC

Questioned Costs Special Tests & Provisions Student Financial Aid

Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. Alexander County DSS has implemented more detailed Indirect Cost Plan review to ensure that the County Manager signed plan is utilized and not the Final (Draft) version. The Business Officer will further train in t...

Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. Alexander County DSS has implemented more detailed Indirect Cost Plan review to ensure that the County Manager signed plan is utilized and not the Final (Draft) version. The Business Officer will further train in the differences between the two documents to ensure the proper one is reviewed and financial data is transferred over to the 1571 mthly cost statements. Proposed Completion Date: Reviewing of the two versions of the Indirect Cost Plans by the DSS Business Officer has been completed as of August 6th, 2024 once the Signed FY23 Indirect Cost plan was obtained. DSS Business Officer will continue a review process every fiscal year once the newly signed plan is received. 2. The DSS Director and Business Office team will review the Official Indirect Cost Plans annually and check the 1571 Statement of Admin. letters mthly to ensure accuracy in the Indirect Cost Plan financial data. Proposed Completion Date: August 6th, 2024

View Audit 339174 Questioned Costs: $1

Finding 519862 (2024-001)

Significant Deficiency 2024

Alexander County

NC

Special Tests & Provisions Student Financial Aid Significant Deficiency

Corrective Action Plan for Finding 2024-001 Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. On May 7th and May 17th, job counseling sessions and written warnings were given to the employees who were flagged for not logging out or locking their screens to protect...

Corrective Action Plan for Finding 2024-001 Name of Contact Person: Michael Dodson, DSS Business Officer Corrective Action: 1. On May 7th and May 17th, job counseling sessions and written warnings were given to the employees who were flagged for not logging out or locking their screens to protect confidential information. In addition, On July 2nd, a staff meeting was completed to review agency policy on PII requirements and expectations and I.T. has changed lock out screen settings to take place after 3 minutes of inactivity on all DSS Computer Systems. Proposed Completion Date: PII Policy Enforcement, Training Reviews, Security Implementations have been completed as of 7/2/24. 2. The DSS Director and Agency Admin. team will randomly check office computers to ensure systems are locked per policy. Proposed Completion Date: July 2, 2024

View Audit 339174

Finding 519811 (2024-002)

Significant Deficiency 2024

Bevill State Community College

AL

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Information on the Federal Program: U.S. Department of Education, Trio Cluster and Appalachian Regional Commission (ARC), Appalachian Area Development Assistance Listing No. 23.002 Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfeder...

Information on the Federal Program: U.S. Department of Education, Trio Cluster and Appalachian Regional Commission (ARC), Appalachian Area Development Assistance Listing No. 23.002 Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfederal entities are also required to establish controls over the disbursement process to ensure compliance with allowable cost requirements. Condition: We selected a Trio sample of 25 payroll charges, containing 56 employee paychecks. Of those 56, five employee's approved pay was not properly documented. The employee had additional pay not on the approved Letter of Appointment (LOA) or the LOA reflected the use of restricted dollars, but the pay was charged to the grant. In addition, of those 56, five employees were charged to a grant that they were not budgeted for. We selected an ARC sample of 10 nonpayroll disbursements to test for controls. Of those 10, one disbursement of four scholarships was not properly documented as approved for payment. Management’s Response: The College will strengthen its policies and procedures surrounding the disbursement process. The College will document approvals on all payroll changes at the college and on the grant budgets. All scholarships will have prior written approval before scholarships will be applied. The College will also amend all grants when needed to properly reflect all job titles and expenditure items. Anticipated Completion Date: February 28, 2025

View Audit 339006 Questioned Costs: $1

Finding 519778 (2024-001)

Significant Deficiency 2024

Northwest Oregon Housing Authority

OR

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2024-001 - Housing Voucher Cluster - Assistance Listing No. 14.871 Recommendation: The Authority should review their HQS inspection policies to ensure that all inspections are performed timely, and that all necessary documentation is maintained for each inspection. Explanation of disagreement with ...

2024-001 - Housing Voucher Cluster - Assistance Listing No. 14.871 Recommendation: The Authority should review their HQS inspection policies to ensure that all inspections are performed timely, and that all necessary documentation is maintained for each inspection. Explanation of disagreement with audit finding: There is no disagreement with the audit finding; however as explained to the auditor, the one unit noted by the audit was an action from 2021 or prior, and the auditor was provided results from current 2023/2024 inspection. Action taken in response to finding: The Northwest Oregon Housing Authority has reviewed its inspection policies regarding timely inspections. All units are being scheduled in a biennial cycle in 2023 and 2024, and beyond, thus resolving this finding. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 12/31/2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Hsu-Feng Andy Shaw, Executive Director, at 503-861-0119.

View Audit 338916

Finding 519774 (2024-009)

Significant Deficiency 2024

Bishop State Community College

AL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.328

Management's Response: Management concurs with the above finding and all documentation for annual reports will be held and kept as required moving forward. This will be implemented with the 2025 annual report.

View Audit 338909

Finding 519769 (2024-012)

Significant Deficiency 2024

Bishop State Community College

AL

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC spe...

Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC specialist helped the college set up an additional "subsequent of term" submission roughly 30 days after the end of the semester but prior to the first upload of the following semester. As a nonattendance taking institution, this timeframe will allow the college a chance to make withdrawal determinations for students who did not officially withdraw but stopped attending at some point in the semester and code them appropriately in Banner. This action has occurred, been tested and implemented as of January 2025.

View Audit 338909

Finding 519766 (2024-004)

Significant Deficiency 2024

Great Plains Housing Authority

ND

HUD Housing Programs Eligibility Significant Deficiency

2024-004 Contact Person David Klein, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP June 30, 2025

View Audit 338886

Finding 519763 (2024-005)

Significant Deficiency 2024

Scotland County Memorial Hospital District

MO

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking

Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to th...

Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to the adverse opinion on the 2022 financial statements and related disclaimer of opinion included in our accompanying 2023 Independent Auditor's Report Response: The hospital has financial covenants including: Maintaining 35 days cash on hand. We are currently at 26 Days Cash on Hand. The hospital has been as low as 6 Days Cash on Hand. To increase our Cash on Hand, we have brought all Revenue Cycle efforts in house, trained new staff, formed cross functional teams with the clinical documentation staff, set goals and work weekly with our teams to gently resolve challenges and move forward. These efforts have rewarded the hospital with increased Days Cash on Hand and improved quality processes in Revenue Cycle. One covenant requires that we maintain strong internal controls. Since the new administration have begun, each month, new internal controls are being established throughout the hospital, Finance department, Materials Management and the Revenue Cycle. On covenant requires a positive bottom line. The hospital has been losing money primarily due to the change in administration, lack of routine processes, recruitment challenges, lack of accuracy in our accounting and revenue cycle. Throughout the hospital and RHC’s, improvement teams are working to both improve quality processes, reduce costs, establish a culture to allow recruitment and improve our bottom line. The hospital has been transparent with the agency and our Board of Directors throughout our change process. More work continues. Responsible Party: Meagan Weber, CEO, Brent Peirick, COO, Carolyn Davies, CFO Estimated Completion Date: 12/31/2026

View Audit 338885

Corrective Action Plans

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