Corrective Action Plans

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VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. For this Digitalization project we have available matching funds of approximately 7 million dollars. IMPLEM...
VIEWS OF RESPONSIBLE OFFICIALS As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. For this Digitalization project we have available matching funds of approximately 7 million dollars. IMPLEMENTATION DATE Awaiting System Implementation RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026....
VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with requirements to ensure Coronavirus State and Local Fiscal Recovery Funds were used for only allowable activities. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $30...
Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with requirements to ensure Coronavirus State and Local Fiscal Recovery Funds were used for only allowable activities. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $300,000,000 Status: Corrective action not taken Corrective Action: The Office does not concur with the audit finding. The state of Washington implemented internal controls and created Fund 706 to track the Coronavirus State and Local Fiscal Recovery Fund (SLFRF) expenditures. The state, through legislation, approved the transfer of $300 million from the SLFRF account to various state transportation accounts under the revenue loss provision. The Office reaffirms that all expenditures from the transportation accounts that received the SLFRF funds were used to maintain government services. The State Administrative and Accounting Manual requires all state agencies to establish internal controls over payments for goods and services, including ensuring payments are lawful and for proper purposes, reviewing payments to ensure they are supported, as well as documenting the review of all payments. State agencies continued to follow their established internal controls to ensure expenditures from the transportation accounts were proper and allowable for both non-SLFRF and SLFRF funds. The Office will continue to: • Work with the U.S. Treasury, through the audit resolution and management decision process, to ensure no questioned costs are required to be repaid. • Document all correspondence with the grantor during the audit resolution process. The conditions noted in this finding were previously reported in finding 2022-018. Completion Date: Not applicable Agency Contact: Sara Rupe Deputy Statewide Accounting Director PO Box 43127 Olympia, WA 98504-3127 (360) 974-9252 sara.rupe@ofm.wa.gov
View Audit 306534 Questioned Costs: $1
As noted in our prior year response, the University continued to have cost transfers in fiscal year 2023 as it reconciled its grants. To limit cost transfers in the future, the following steps have been taken by the University: • The Controller’s Office along with the Office of the Vice President of...
As noted in our prior year response, the University continued to have cost transfers in fiscal year 2023 as it reconciled its grants. To limit cost transfers in the future, the following steps have been taken by the University: • The Controller’s Office along with the Office of the Vice President of Research configured our accounting system with an automated control that prevents general (non-payroll) expenditures from being charged to the grant after the period of performance end date, one root cause of cost transfers. • For payroll expenditures, post-award specialists updated grant labor costing allocations in our accounting system to contain an end date that coincides with the period of performance end date. This change in Workday restricts labor costs from being charged after the period of performance. The University’s post-award specialist review grant labor costing allocations on a periodic basis. • With collaboration between the payroll department, the Controller’s Office and post-award specialists, before each payroll is processed within the accounting system, grants that have ended are identified and the payroll expenditures are removed from the feed and not charged to the grant. • On-going training on data certification by post-award grant managers has improved grant-expenditure compliance and data accuracy. In addition, the Controller’s Office implemented a process in which post-award grant managers are now reviewing grant level budget versus actual reporting on a periodic basis to identify errors timely (i.e. before the 90 day threshold). Additionally, the University’s Workday team is exploring additional functionality within our Workday grants management module to build in additional expense approvals, specifically for labor, before those expenses are charged to the grant to reduce future cost transfers. As part of the University’s corrective action plan, during fiscal year 2023 the sponsored programs accounting team recalculated fringe and indirect costs on all federal grants to ensure the correct expense was recorded to each grant. During this reconciliation process cumulative award to date errors were identified and corrected. The sponsored program accounting team continues to reconcile fringe and indirect costs on cost transfers at the grant level on a periodic basis to ensure accuracy. Tara Thomason, Controller and Assistance Vice President, is responsible for addressing the above items by June 2024.
View Audit 300294 Questioned Costs: $1
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally re...
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
2022-005 Significant Deficiency in Controls over Compliance: Administrative Requirements of Uniform Guidance-Administrative Policies The schools have documented their administrative policies effective 3/1/2023.
2022-005 Significant Deficiency in Controls over Compliance: Administrative Requirements of Uniform Guidance-Administrative Policies The schools have documented their administrative policies effective 3/1/2023.
Finding 32029 (2022-004)
Material Weakness 2022
FINDING 2022-004 Contact Person Responsible for Corrective Action: George ann Ewald, Director of Finance & HR Contact Phone Number: (574) 277-4452 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Finance & HR will expand Fund 8700 to i...
FINDING 2022-004 Contact Person Responsible for Corrective Action: George ann Ewald, Director of Finance & HR Contact Phone Number: (574) 277-4452 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Finance & HR will expand Fund 8700 to include adding line items for all allowable reimbursement costs associated with each firefighter position covered by the 2019 Staffing for Adequate Fire and Emergency Response (SAFER) federal grant. The Director of Finance & HR will ensure that all funds used to compensate each covered firefighter position will be paid entirely out of Fund 8700, only. This action will result in a negative value for Fund 8700 until which time the fund is reimbursed the allowable costs under the provisions of the federal grant. The Director of Finance & HR will generate a report for each reimbursement request, which will be limited to include only the payroll dates of the period for which the request is being submitted. The Fire Chief will review and confirm that all associated costs have been withdrawn from Fund 8700. The Fire Chief will then direct the Assistant Fire Chief to complete the reimbursement request via the FEMA GO website. Once the reimbursement request has been submitted, the Assistant Fire Chief will print the completed reimbursement request documents and obtain signatures from each of the following individuals: 1. Prepared By: (NAME), Director of Finance & HR 2. Reviewed & Approved By: (NAME), Fire Chief 3. Submitted By: (NAME), Assistant Fire Chief Anticipated Completion Date: ? Implementation: June 2023
Compliance requirement ? Allowed Cost /Cost Principle Institutional Comments on Findings and Recommendations: 1. The institution does not concur with the auditor finding because the referenced transaction was below the "Micro-purchase" threshold and does not require a quotation. The FAR increase the...
Compliance requirement ? Allowed Cost /Cost Principle Institutional Comments on Findings and Recommendations: 1. The institution does not concur with the auditor finding because the referenced transaction was below the "Micro-purchase" threshold and does not require a quotation. The FAR increase the "Micro-purchase" threshold for natural disasters and national emergencies, among others. The invoice amount of $5899 was a continuation of an initial project under this contractor which have the unique security passwords, IT protocols and other IT requirements for the uniform implementation of intelligent classrooms for remote distance education. Accordingly, the institution does not request a quote. The institution followed the referenced guidelines in the determining the allowability of costs. Additionally, an external consultant reviewed the transaction and costs prior to request reimbursement. The 2 CFR Part 200, Appendix XI Compliance Supplement guide, issued April 2022, makes referenced to the FAQ's and Other Guidance containing information pertinent to the compliance requirements described in the document and encouraged auditor to regularly check the HERF Websites for updated FAQ's and other pertinent guidance and reporting information. The institution followed those referenced FAQ's and guidelines, among other sound administration practices, in the use of the grants. The referenced Compliance Supplemental, under "Activities Allowed or Unallowed" states: "Institutions must demonstrate that costs incurred are allowable under the relevant statutory provision and consistent with the purpose of the ESF "to prevent, prepare for, and respond to coronavirus"". The institution used $5,899 paid to the guidelines as indicated to contractor, to continue enhancing the distance learning program in preventing the spread and contamination of the coronavirus among professors and students by enabling remote distance education. The direct charges for this transaction to the federal award was for allowable costs under the instructions, federal grant and FAQs guidelines as indicated. 2. The institution does not concur with the auditor finding because of what is discussed in No 1 above. In the two cases mentioned, the cost quote may not agree with the invoice, because of some additional services requested, but the amount of the invoice was the correct amount paid and actual cost used to draw the HEERF funds. These invoices were for furniture and partitions divisions, to enable the remote distance education, avoiding physical contact of students and professors, to prevent, prepare for and respond to the COVID-19 emergency. Once again, these incurred and direct charges to the federal award complied with the HEERF objectives and were allowable costs under the authorized uses in the grant award and HEERF guidelines. 3. The institution does not concur with the auditor finding. The referenced three cases may not have a specific or expressed "acknowledgement of receipt" statement, but the acknowledgement was validated by UTC management and with the signatures when the check was issued. Nevertheless, the costs incurred in these invoices were authorized and incompliance with HEERF program and ESF purpose. The direct charges for this transaction to the federal award was for allowable costs under the instructions, federal grant and FAQs guidelines as indicated. 4. Institution does not, firmly, concurs with the auditor finding. This should not even be a finding because the institution strictly followed the FAQs published on March 19, 2021 to calculate the lost revenue and using a comparison between FY-20 and FY 21. That guideline described "Loss of Revenue" as "...those revenues and institution of higher education otherwise expected but were reduced or eliminated as a result of the novel coronavirus 2910 (COVID-2019) pandemic. As such, lost revenues can only be estimated". Nerveless, the result would have been relatively the same if we have use FY21 audited financials. Given the many factors and complexities of the unusual process, the institution followed a conservative approach and reduced those revenue items that have an increase between fiscal year from those with a loss of revenue. Therefore, the institution netted the potential amount of lost revenue to claim. Accordingly, the net amount resulted in $280,929.84. The potential loss of revenue amount could be greater but the institution decided to only claim the referenced estimated amount. These calculations and analysis were further discussed and evaluated by an officer of the Department of Education, with no recommendation on claiming a higher amount because the amount claimed was less than the estimated potential. The guideline indicates: "Reimbursement for lost revenue is allowable for the Institutional Portion program...". The institution claimed this loss of revenue amount from their institutional portion, complying with the HEERF guidelines and the authorized use of the funds. The direct charges for this transaction to the federal award was for allowable costs under the instructions, federal grant and FAQs guidelines as indicated. a. The institution used unaudited figures for FY21 because the audited financial statements were not completed at the time of the calculation. The institution revised the calculations with the audited financial statements, and the results were the same and the claimed estimated amount did not changed. Once again and in accordance with the guidelines, we were estimating the lost revenue with the data available at the moment. b. The institution followed the recommended HEERF guidelines for this complex and novel exercise. The institution considered under the analysis; those revenues otherwise expected but that were reduced as a result of the novel COVID-2019. The contributions as "Support Revenue" from related entities, which were a significant source of revenue for the institution, was not claimed as loss of revenue. The institution specifically claimed those lost revenue items as authorized in the guidelines. Therefore, once again, the UTC was in compliant with the lost revenue referenced guidelines. The direct charges for this transaction to the federal award was for allowable costs under the instructions, federal grant and FAQs guidelines as indicated. c. As explained above, the institution followed a conservative approach and only claimed a net amount of all lost revenue items. The institution only claimed those estimated revenue items, as authorized in the guideline, that suffer a loss between the two fiscal years considered in the evaluation. This was further evaluated by an officer of the DOE. As the guidelines described, since the lost revenues can only be estimated, the institution correctly, analyzed and calculated the best conservative/reasonable estimate of loss revenue with the available data at the moment. Even if we used the auditors' recommended items, the results would have been the same and no revenue item was claim out of the authorized or allowable costs from the guidelines. The direct charges for this transaction to the federal award was for allowable costs under the instructions, federal grant and FAQs guidelines as indicated. Actions Taken or Planned: The institution understands that the incurred and direct charges to the federal award complied with the HEERF objectives and were allowable costs under the authorized uses in the grant award and HEERF guidelines and no further was required.
#2022-002: Material Weakness in Controls over Compliance: Administrative Requirements of Uniform Guidance -Administrative Policies Recommendations: Grand Rapids Christian Schools should consider the following written policy additions or updates: ? Financial Management (2 CFR 200.302) The financial m...
#2022-002: Material Weakness in Controls over Compliance: Administrative Requirements of Uniform Guidance -Administrative Policies Recommendations: Grand Rapids Christian Schools should consider the following written policy additions or updates: ? Financial Management (2 CFR 200.302) The financial management policy should include records documenting compliance, and the tracking of funds to determine that expenditures are in accordance with the terms and conditions of the federal awards. The financial management and reporting system must provide the following : ? Identification - Title of the award, CFDA number ? Complete disclosure of accurate and current financial results of each federal award ? Source and application of funds for federal award activity ? Record retention and access - define the time period for which records must be kept (can vary by grant agreement), and who has the ability access the records (?200.333 - ?200.337) ? Written procedure to implement cash management requirements (see below) ? Written procedures for determining the allowability of costs (see below) ? Cash Management (2 CFR 200.305) A written policy is required by Uniform Guidance detailing the Organization's procedures to minimize the time that elapses between draw and expenditure of federal dollars. ? Allowable Costs (2 CFR 200.302(b)(7)) The Organization must have written procedures for determining the allowability of costs in accordance with Subpart E - Cost Principles of Uniform Guidance and the terms and conditions of the Federal award. This includes the determination of allowable costs and the review of this determination. The standard assumes policies and procedures are in place for disbursements, and the allowable cost policy will demonstrate how the Organization ensures compliance. The criteria for costs to be considered allowable are documented within 2 CFR 200.403. ? Procurement Standards (2 CFR 200.317 - 200.326) The Organization must have a written policy that promotes full and open vendor competition, conflict of interest policies should cover employees as well as the organization, and general purchase requirements with specific thresholds as set forth by the Uniform Guidance. There are five allowable procurement methods as described in ?200.320, depending upon the dollar value of the purchase or contract. Views of Responsible Officials and Planned Corrective Actions: ? Grand Rapids Christian Schools follows procurement and record retention standards provided by the USDA. ? GRCS does not have actual written policies and procedures for Financial Management, Cash Management, Allowable Costs, and Procurement Standards, but do have practices in place to follow USDA guidelines. In the case of cash management, the only location that takes cash is GRCHS. In that instance, along with Meal Magic, cash registers are zeroed out and balanced to Meal Magic and cash deposits are made daily. ? GRCS Business Office will work with the Food Service Director to begin formulating written policies and procedures specific to Grand Rapids Christian Schools. GRCS will utilize the resources from Uniform Guidance and Code of Federal Regulations (CFR) to develop policies that are compliant with those requirements prior to June 30, 2023.
Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with requirements to ensure Coronavirus State and Local Fiscal Recovery Funds were used only for allowable activities. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $30...
Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with requirements to ensure Coronavirus State and Local Fiscal Recovery Funds were used only for allowable activities. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $300,000,000 Status: Corrective action not taken Corrective Action: The Office does not concur with the audit finding. The state of Washington created a separate fund to track the Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) expenditures. The state, through legislation, approved the transfer from the CSLFRF account to various state transportation accounts. The Office reaffirms that all expenditures from the transportation accounts that received the CSLFRF funds were used to maintain government services. The State Administrative and Accounting Manual requires all state agencies to establish internal controls over payments for goods and services, including ensuring payments are lawful and for proper purposes, reviewing payments to ensure they are supported, as well as documenting the review of all payments. State agencies continued to follow their established internal controls to ensure expenditures from the transportation accounts were proper and allowable for both non-CSLFRF and CSLFRF funds. The Office will continue to: ? Work with the U.S. Treasury through upcoming desk audits to ensure no questioned costs are required to be repaid. ? Document all correspondence with the grantor during the audit resolution process. Completion Date: Not applicable Agency Contact: Brian Tinney Statewide Accounting Director PO Box 43127 Olympia, WA 98504-3127 (564) 999-1781 brian.tinney@ofm.wa.gov
View Audit 23129 Questioned Costs: $1
The Office of Vice President of Research and the Controller?s Office will collaborate to ensure effort verification reports are returned no later than 30 calendar days after they have been distributed, including escalating noncompliance to appropriate University leadership. These improvements are ex...
The Office of Vice President of Research and the Controller?s Office will collaborate to ensure effort verification reports are returned no later than 30 calendar days after they have been distributed, including escalating noncompliance to appropriate University leadership. These improvements are expected to be completed by December 2023. The Controller?s Office will review its indirect costs configurations within the grants module of Workday to ensure the automated calculation of indirect costs is correct. In addition, the Sponsored Programs Accounting team will manually reconcile indirect costs periodically at the grant level. These improvements are expected to be completed by December 2023. The University continues to have cost transfers in fiscal year 2023 as it reconciles its grants. However, to limit cost transfers in the future, the Office of Vice President of Research and the Controller?s Office worked with the University?s Workday Finance team to configure its accounting system with an automated control that prevents general (non-payroll) expenditures from being charged to the grant after the period of performance end date, one root cause of cost transfers. In addition, for payroll expenditures, the above teams updated grant labor costing allocations in its accounting system to contain an end date that coincides with the period of performance end date which restricts labor costs from being charged after the period of performance. The post award specialists will begin reviewing the labor costing allocations on a periodic basis. Also implemented in fiscal year 2023, before each payroll is processed by the Director of Payroll within the accounting system, grants that have ended are identified by the Assistant Controller and Director of Sponsored Program Accounting and the payroll expenditures are removed from the feed and not charged to the grant. The University has also hired individuals whose sole responsibility is to review general (non-payroll) expenditures charged to grants. Further, the University?s post award specialists are continually trained on the importance of allowed and unallowed expenditures and are now reviewing grant level budget versus actual reporting on a periodic basis to identify noncompliance. Tara Thomason, Controller and Assistance Vice President, is responsible for addressing the above items by December 2023.
View Audit 17372 Questioned Costs: $1
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally re...
Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026
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