Corrective Action Plans

Finding 1216525 (2024-011)

Material Weakness 2024

OK

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

The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.

View Audit 403025

Finding 1216524 (2024-010)

Material Weakness 2024

Pottawatomie County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.

View Audit 403025

Finding 1216383 (2024-003)

Material Weakness 2024

County of Carbon

PA

Student Financial Aid Subrecipient Monitoring Reporting

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entit...

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity Identifying Number: not available; 14.228, Community Development Block Grants, Passed Through Pennsylvania Department of Community and Economic Development, U.S. Department of Housing and Urban Development; 93.558, Pass-Through Granter #'s C000073823, C000075969, C000082698, C000086225, and C000088719, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available, 21.023, Emergency Rental Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available. Prior Year Finding Number: 2023-005 Criteria: Pursuant to the provisions of the Uniform Guidance, under Section 200.512(a), the County is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (September 30) of the following year. Condition/Context The County's Single Audit and reporting package was delayed for the year ended December 31, 2023 beyond the nine-month due date. Effect: The County is not in compliance with certain requirements of the Uniform Guidance, including the Single Audit reporting requirements. Questioned Costs: None. Cause: Reconciliations and reports were not completed on a timely basis, and therefore, the completion and filing of its December 31, 2023 Single Audit and reporting package was not prioritized. Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Views of Responsible Officials and Planned Corrective Actions: The County plans to have information ready for the auditors to get 2024 done in a reasonable time frame. Between staffing and priorities, the County hopes to have cleared by the 2025 audit.

View Audit 402918

Finding 1216303 (2024-003)

Material Weakness 2024

Connecticut Children's Medical Center and Subsidiaries

CT

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconcil...

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconciliation Workflow and System Controls The State of Connecticut utilizes CT WiZ, a centralized vaccine ordering and supply management system. To maintain ordering privileges, the program enforces a strict regulatory safeguard: inventory must be fully reconciled every two weeks. Failure to complete this reconciliation triggers an automated, hard stop within CT WiZ, preventing any additional vaccine orders from being placed. To ensure absolute accuracy and data integrity, our practice executes a standardized, threepart reconciliation process that typically leverages a dual-provider verification model: • Part 1: Physical Count (Floor Staff): Clinical nurses on the floor conduct a manual, physical inventory of all vaccine doses, cross-referencing exact lot numbers and expiration dates. • Part 2: Electronic Health Record Alignment (Coordinator): The designated Vaccine Coordinator reviews the physical counts against the electronic Lot Manager log within Epic to identify and resolve any administrative discrepancies. • Part 3: State System Data Entry (Coordinator): The verified quantities are formally submitted into the CT WiZ portal to complete the biweekly cycle and clear the system for subsequent orders. Staffing Redundancy: While a single coordinator may occasionally manage all three steps if cross-covering the floor, the workflow is deliberately structured to divide tasks between floor nurses (physical counts) and site coordinators (via EMR reconciliation and CT WiZ entry). 2. Vaccine Oversight Team Vaccine operations are managed through a centralized leadership structure with site-specific accountability to ensure consistent oversight at clinic locations. Vaccine operations may be managed by a senior nurse practice manager, practice manager, lead nurse or a backup coordinator. This triad ensures continuous coverage, strict adherence to ordering schedules, and immediate troubleshooting for storage or inventory alerts. 3. Storage, Handling, and Annual Training Compliance In alignment with state oversight expectations and the strict guidelines governing CVP asset management, cold-chain integrity and proper handling are heavily protected. To mitigate risk and standardize knowledge across all care teams, the following educational requirements are mandated: • Mandatory Annual Training: All rostered nursing personnel - including core staff, float pool, and per diem nurses - are strictly required to complete annual training modules dedicated to CVP guidelines and CDC Storage and Handling. • Verification of Competency: Training must be completed through the official CDC TRAIN platform, and employees must submit their earned certificates of completion to clinical leadership to be maintained on file for audit readiness. Name(s) of Contact Person(s) Responsible for Corrective Action: Matthew Farr, VP Ambulatory Operations, Cynthia O’Brien, Senior Nurse Manager Practice Operations Anticipated Completion Date: 01/01/2026

View Audit 402778

Finding 1216237 (2024-010)

Material Weakness 2024

Barclay College

KS

Subrecipient Monitoring Material Weakness

2024-010 Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: We will review items not fully implemented. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

Finding 1216230 (2024-008)

Material Weakness 2024

Barclay College

KS

Student Financial Aid Reporting Subrecipient Monitoring

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice Pr...

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

Finding 1216017 (2024-001)

Material Weakness 2024

Southeast Chicago Chamber of Commerce

IL

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.507 § 200.512

Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion a...

Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion and submission of future Single Audit reporting packages.

View Audit 402560

Finding 1215997 (2024-001)

Material Weakness 2024

City of Lakewood

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

The City will strengthen its process by requiring documented SAM.gov suspension and debarment checks for all applicable federally funded vendors by ensuring our grant requirements document is up to date and accessible to all staff. The City is currently compliant with suspension and debarment requir...

The City will strengthen its process by requiring documented SAM.gov suspension and debarment checks for all applicable federally funded vendors by ensuring our grant requirements document is up to date and accessible to all staff. The City is currently compliant with suspension and debarment requirements and will ensure the grants requirement document is updated and all federal contracts remain compliant going forward.

View Audit 402546

Finding 1215976 (2024-004)

Material Weakness 2024

JEWISH FAMILY SERVICES OF GREENWICH

CT

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.403

The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls o...

The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls over all Other Than Personal Services (OTPS) expenditures. To ensure full compliance with 2 CFR 200.303 and 200.403, Finance has deployed the following enhancements to our accounts payable workflows: • Strict Electronic Approval Workflow: Finance has established a stringent review and approval protocol that requires direct involvement from Program Directors and Department Heads. All OTPS expenditures are now routed through a formalized electronic workflow, which mandates documented review and secure electronic signatures from authorized leadership prior to any payment processing. • System-Integrated Documentation: The new process strictly requires that all supporting documentation-including invoices, receipts, and evidence of allowability-be provided upfront. These documents are now uploaded and attached directly to the specific transaction within the accounting program, creating a permanent, easily accessible, and audit-ready trail for every federal charge. • Targeted Training and Oversight: To support this modernized workflow, Finance is providing targeted training to all staff responsible for initiating and approving transactions, ensuring a clear understanding of Uniform Guidance requirements. Furthermore, Finance leadership conducts periodic supervisory reviews directly within the accounting system to verify that all electronic approvals are captured and source documents are properly attached.

View Audit 402530

Finding 1215975 (2024-003)

Material Weakness 2024

JEWISH FAMILY SERVICES OF GREENWICH

CT

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties § 200.300

Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and institut...

Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and instituted the following corrective actions: • Updated Internal Signature Policy: We have drafted a strict internal policy requiring the primary case manager-and any other staff actively working on a case-to sign and date all required enrollment documents. This explicitly includes signing intake forms and completing the interpreter sections, where applicable. This policy ensures there is never any ambiguity regarding who is handling the case. • Mandatory Supervisory Review: To enforce this new standard, our internal policy now requires Program Managers and Directors to systematically review each individual case file. Leadership must verify that all required staff signatures, interpreter sign-offs, and eligibility approvals are fully documented before a client's enrollment is considered complete. • Standardized Case Coversheet: To immediately resolve the issue of identifying case handlers, we are implementing a standardized enrollment coversheet for all new files. This document clearly assigns the primary case manager on day one and requires a final supervisory signature to formally authorize the eligibility review. • Targeted Training and Spot-Checks: We are conducting immediate refresher training for all program staff to clarify exactly which signatures are required on each document. Furthermore, leadership will conduct routine, random spot-checks of active case files each month to verify that staff are consistently adhering to this policy in real-time. By formalizing our signature requirements and mandating director-level reviews, we are confident this updated workflow establishes clear accountability and fully resolves the finding.

View Audit 402530

Finding 1215973 (2024-001)

Material Weakness 2024

JEWISH FAMILY SERVICES OF GREENWICH

CT

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.302

Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorpor...

Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorporate the auditors' feedback during the FY24 audited period. However, the Organization took immediate, proactive steps to deploy enhanced internal controls for FY25 to ensure continuous alignment with federal standards. To ensure strict adherence to 2 CFR § 200.302(a), we are actively implementing a more regular reconciliation process between government grant revenue claimed and actual revenue earned. As a key part of this initiative, the Organization has developed and deployed new internal financial tools designed to incorporate automation into our daily workflows. By utilizing these automated tools-such as standardized templates for recording cash receipts and systematically clearing Accounts Receivable-we have significantly enhanced the accuracy of our data entries and reduced the risk of manual misstatements. Our ongoing objective is to leverage these tools to establish clear, standardized documentation procedures, ensuring that all financial reports and claims are consistently generated from a reconciled general ledger. Management remains fully committed to dedicating the necessary time and resources to mature these financial controls and ensure robust compliance with federal regulations.

View Audit 402530

Finding 1215914 (2024-005)

Material Weakness 2024

South Routt School District Re-2

CO

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.512

The District acknowledges the failure to submit the Single Audit data collection form for the fiscal year ended June 30, 2023 to the Federal Audit Clearinghouse within the required 30-day post-opinion deadline. The form was never submitted for that fiscal year. Additionally, for the fiscal year ende...

The District acknowledges the failure to submit the Single Audit data collection form for the fiscal year ended June 30, 2023 to the Federal Audit Clearinghouse within the required 30-day post-opinion deadline. The form was never submitted for that fiscal year. Additionally, for the fiscal year ended June 30, 2024, the District’s accounting records were not available until March 2026, causing the audit to extend well beyond the required nine-month completion deadline and resulting in further noncompliance with Single Audit reporting requirements. Current management has improved procedures related to the management of Single Audit compliance obligations. The District, in coordination with the third-party accounting firm and the external auditor, has established a compliance calendar that identifies all Single Audit submission deadlines and assigns responsibility for preparation, certification, and submission of the data collection form. Procedures have been implemented to ensure accounting records are available on a timely basis to support completion of the audit within the required nine-month window, starting with the fiscal year ending June 30, 2026. We plan to ensure that the fiscal year ended June 30, 2023 data collection form is submitted to the Federal Audit Clearinghouse and that the fiscal year ended June 30, 2024 Single Audit is completed and submitted within 30 days of the audit opinion date, and that all future Single Audit data collection forms are submitted in a timely manner. Estimated date of implementation of the corrective action plan: Ongoing Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood

View Audit 402487

Finding 1215899 (2024-004)

Material Weakness 2024

South Routt School District Re-2

CO

Subrecipient Monitoring Cash Management Internal Control / Segregation of Duties § 200.303

The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colora...

The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colorado Department of Education, for the fiscal year ended June 30, 2024. Specifically, the District lacked adequate segregation of duties over payroll and human resources processes, both of which were performed by a single employee without a secondary review. In addition, the District did not maintain adequate reimbursement request documentation or regularly reconcile ESSER grant expenditures to reimbursement requests, as required under 2 CFR 200.303. These conditions resulted in material audit 60 adjustments, significant audit delays, and the engagement of a third-party accounting firm to reconstruct grant records. Notwithstanding these control deficiencies, the District was in compliance with allowable activities, allowable costs, and cash management requirements, as allowable costs exceeded the amounts requested for reimbursement. Current management has improved procedures related to the oversight of federal grant compliance and payroll processes. The District has engaged a third-party accounting firm and hired new staff to assist with grants reconciliation, reimbursement request preparation, and internal controls over federal awards. A secondary review process has been established for payroll and human resources transactions to ensure that no single employee has unchecked control over these functions. Grant reconciliation responsibilities have been reassigned to incorporate segregation of duties, and a defined schedule for monthly ESSER reconciliations and reimbursement submissions has been implemented. We plan to have all ESSER grant activity fully reconciled, reimbursement documentation complete and available for review, and monthly reconciliation and secondary review procedures operational and documented for all applicable federal grant programs prior to the start of the audit process. Estimated date of implementation of the corrective action plan: June 30, 2026 Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood

View Audit 402487

Finding 1215762 (2024-004)

Material Weakness 2024

Harvest Hope Food Bank

SC

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...

2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402413

Finding 1215758 (2024-003)

Material Weakness 2024

Harvest Hope Food Bank

SC

Subrecipient Monitoring Eligibility Material Weakness

2024-003 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@har...

2024-003 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402413

Finding 1215754 (2024-002)

Material Weakness 2024

Harvest Hope Food Bank

SC

Reporting Equipment & Real Property Management Subrecipient Monitoring

2024-002 SCDA Special Tests Significant Deficiency and Non-Material Noncompliance Corrective Action: We've hired competent staff that understand how to reconcile inventory to the general ledger. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402413

Finding 1215722 (2024-004)

Material Weakness 2024

Livingston Parish Council

LA

Subrecipient Monitoring § 200.303 § 200.331

The Parish has established a subrecipient checklist to assess risk and compliance. The checklist will be completed as an additional measure to ensure the standards outlined in the "Grant Adminstration Policies & Procedures" are met.

View Audit 402388

Finding 1215484 (2024-006)

Material Weakness 2024

Neighborhood Service Center, Inc.

MD

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional ...

U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional training over fiduciary responsibilities under the CSBG Act. The Neighborhood Service Center, Inc. should adhere to the board composition and vacancy reporting requirements. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Executive Director and Deputy Director of the Neighborhood Service Center are actively recruiting individuals to join the Board. The Deputy Director, or their designee, will provide information to the Maryland Department of Housing and Community Development on the Board composition and vacancies on a monthly basis. Name of the contact persons responsible for corrective action: E. Yvette Robinson, Deputy Director Planned completion date for corrective action plan: For immediate implementation and ongoing.

View Audit 402137

Finding 1215482 (2024-004)

Material Weakness 2024

Neighborhood Service Center, Inc.

MD

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.403

U.S. Department of Health and Human Services - Community Service Block Grant Material Weakness in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc require both check signers to evidence review and approval of supporting documentation ...

U.S. Department of Health and Human Services - Community Service Block Grant Material Weakness in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc require both check signers to evidence review and approval of supporting documentation prior to signing the check. Documentation of that review and approval shold be readily for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: All checks presented for signatures have supporting documentation attached. Authorized check signers are instructed to review all documentation for appropriate authorization, payee name, and amounts prior to signing checks. No checks are signed without supporting documentation. The agency will require check signers to initial the check request page or other supporting documentation when signing checks for grant expenditures. The Neighborhood Service Center, Inc. is implementing a procedure to provide the Finance Committee of the Board with a listing of all checks issued between Board meetings for their review/reference. The Finance Director keeps all check stock locked in their office to avoid any potential misuse of the check stock. Name of the contact persons responsible for corrective action: R. Andrew Hollis, Executive Director Michele Lednum, Finance Director Planned completion date for corrective action plan: For immediate implementation and ongoing.

View Audit 402137

Finding 1215424 (2024-003)

Material Weakness 2024

Fasd United Inc.

DC

Subrecipient Monitoring Allowable Costs / Cost Principles

The Organization reduced the indirect rate charged to the grant to the de minimis 10% during 2024.

View Audit 402036

Finding 1215167 (2024-003)

Material Weakness 2024

YWCA of Glendale and Pasadena

CA

Subrecipient Monitoring Reporting Significant Deficiency § 200.329

Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.

View Audit 401831

Finding 1214964 (2024-001)

Material Weakness 2024

Ecumenical Social Action Committee, Inc.

MA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors...

Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors will be adjusted each period to ensure that account and ledger totals are properly maintained and recorded. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over bank reconciliations, accounts payable and grants receivable. Controls and the policies and procedures have been reviewed with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely reconciliations. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026

View Audit 401734

Finding 1214940 (2024-005)

Material Weakness 2024

First Choice Community Healthcare, Inc.

NM

Special Tests & Provisions Subrecipient Monitoring Eligibility

2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income doc...

2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2026

View Audit 401709

Finding 1214910 (2024-001)

Material Weakness 2024

City of Galion

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Prefe...

The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Preference will be included in future contracts where federal funds are expended. The Safety-Service Director will check for SAM exclusions and will request a waiver to this requirement if necessary.

View Audit 401666

Finding 1214878 (2024-001)

Material Weakness 2024

Auburn Community Hospital

NY

Subrecipient Monitoring Reporting Significant Deficiency § 200.512

We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.

View Audit 401608

Corrective Action Plans

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