Corrective Action Plans

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Funds in 1406 will be drawn down directly after obligation.
Funds in 1406 will be drawn down directly after obligation.
The Authority will utilize the reimbursement method and process payment to the vendor before requisitioning funds from ELOCCs.
The Authority will utilize the reimbursement method and process payment to the vendor before requisitioning funds from ELOCCs.
The City will implement procedures to obtain, review, reconcile, and retain supporting documentation for all Federal award activity, including costs paid on the City's behalf by the Ohio Department of Transportation. Responsibility for monitoring and documenting these activities will be assigned to ...
The City will implement procedures to obtain, review, reconcile, and retain supporting documentation for all Federal award activity, including costs paid on the City's behalf by the Ohio Department of Transportation. Responsibility for monitoring and documenting these activities will be assigned to appropriate personnel, and management will review and reconcile the amounts reported on the Schedule of Expenditures of Federal Awards to the information provided by ODOT.
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: We recommend that the Organization strengthen controls over participant eligibility by implementing procedures to regularly monitor participant eligibility periods, track ORR...
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: We recommend that the Organization strengthen controls over participant eligibility by implementing procedures to regularly monitor participant eligibility periods, track ORR eligibility dates, and timely close cases that exceed the maximum allowable service period. In addition, the Organization should verify and document Minnesota residency prior to providing services, retain supporting eligibility documentation in participant files, and perform periodic monitoring to ensure compliance with program eligibility requirements. Management should not rely solely on system-generated notifications to identify participants approaching eligibility expiration. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KOM will strengthen its participant eligibility procedures by implementing a process to regularly monitor participant eligibility periods and track applicable ORR eligibility dates. Cases that reach or exceed the maximum allowable service period will be identified and closed timely. KOM will also establish procedures to verify and document Minnesota residency before services are provided and to retain appropriate eligibility documentation in participant files. Periodic monitoring will be performed to confirm ongoing compliance with program eligibility requirements, rather than relying solely on system-generated notifications to identify approaching eligibility expiration dates. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: December 31, 2026.
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its controls over Executive Director payroll by requiring payroll timesheets and related payroll records to be reviewed and approved by an ...
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its controls over Executive Director payroll by requiring payroll timesheets and related payroll records to be reviewed and approved by an individual with appropriate oversight authority, such as the Board Chair, Treasurer, or another designated board representative. Management should maintain documentation of such approval and periodically monitor compliance with the control. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in October 2026, KOM will implement an independent review and approval process for the Executive Director's payroll. A designated Board member will review and approve the Executive Director's payroll records. To facilitate this control, the designated Board member will be established in Paylocity with the appropriate manager-level access necessary to perform the approval. KOM will coordinate with the designated Board member to ensure that the review and approval can be completed within the organization's time-sensitive semi-monthly payroll cycle and that evidence of the approval is retained. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: November 30 , 2026.
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its internal controls over grant reimbursement requests by ensuring all requests are reviewed and approved by the authorized Executive Dire...
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its internal controls over grant reimbursement requests by ensuring all requests are reviewed and approved by the authorized Executive Director prior to submission to the grantor. Management should maintain documentation evidencing the review and approval and perform periodic monitoring to ensure compliance with established approval and segregation of duties requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective July 2026, KOM implemented an enhanced review and approval process for RPO reimbursement invoices. Each invoice is subject to review by two executives and requires two levels of approval. The Program Director and Executive Director are primarily responsible for the review and approval process. When the Executive Director is unavailable, the Finance Director provides the required review and approval. This process is intended to ensure appropriate oversight and documented authorization before reimbursement requests are submitted. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: November 30,2026
Management agrees with the finding. CARD's primary federal funding ended on August 31, 2026, resulting in the cessation of operations and a substantial reduction in management and administrative resources. During the wind-down, the reduced administrative capacity and the inability to convene the Boa...
Management agrees with the finding. CARD's primary federal funding ended on August 31, 2026, resulting in the cessation of operations and a substantial reduction in management and administrative resources. During the wind-down, the reduced administrative capacity and the inability to convene the Board of Directors to review and approve the audited financial statements before the Federal Audit Clearinghouse filing deadline resulted in the missed submission deadline. CARD will submit the SF-SAC data collection form and Single Audit reporting package to the Federal Audit Clearinghouse promptly following final approval and issuance of the audited financial statements. The Board has designated Tracy McNew, Executive Director, as the individual responsible for coordinating the remaining audit, federal award closeout, and financial reporting responsibilities. The designated individual will maintain a calendar of all remaining deadlines, coordinate electronic or written Board approval when a formal meeting cannot be held, and retain confirmation that each required submission has been accepted. These procedures will remain in place until CARD has completed its federal award closeout requirements and dissolution responsibilities. Responsible person: Tracy McNew, Executive Director. Anticipated completion date: October 2026.
Recommendation: We recommend that the City review and update internal controls over the completion and submission of monthly program reports to ensure the accuracy of the information being reported and to ensure that supporting underlying documentation is properly retained. As part of this process, ...
Recommendation: We recommend that the City review and update internal controls over the completion and submission of monthly program reports to ensure the accuracy of the information being reported and to ensure that supporting underlying documentation is properly retained. As part of this process, the City should consider utilizing members of the Finance Department as the monthly reports contain certain financial information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA established a process by which Housing staff generate the reports required to prepare the VMS and provide the Finance Department staff a copy in order to document timing and ensure additional review. Also, the RBHA and Finance revised the City’s account structure for Housing-related expenses to align with the City’s account setup with VMS reporting. The RBHA will provide monthly reports to the Finance Department and the financial consultant to document the timing of the reports and facilitate an independent review and ensure the monthly submissions are properly reviewed, approved, and retained for audit purposes. Name(s) of the contact person(s) responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: January 2026
Recommendation: We recommend the City establish procedures to ensure that the review and approval processes are clearly documented within each tenant file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management...
Recommendation: We recommend the City establish procedures to ensure that the review and approval processes are clearly documented within each tenant file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management recognizes the importance of maintaining adequate documentation to demonstrate the required reviews and approvals are performed timely and consistently at all times. The RBHA established procedures to monitor and ensure proper file review in the prior-year (2023-2024) corrective action by creating a new checklist for a supervising team member to review intake files for accuracy, to document approval, release the Housing Assistance Payments, and maintain a record of the signed checklist in the participant file. To prevent recurrence, new staff will be informed of this requirement. Name(s) of the contact person(s) responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: December 2025
Recommendation: We recommend that the City review and update internal controls to ensure that the FDS is completed and submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA contract...
Recommendation: We recommend that the City review and update internal controls to ensure that the FDS is completed and submitted in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA contracted a financial consultant to assist with the preparation and timely submission of monthly and annual financial reports in 2025. The RBHA also reinforced internal procedures to ensure staff prepare and provide the necessary financial data to the consultant in advance of the FDS submission deadlines as soon as the Single Audit is complete. Staff will continue to utilize calendar reminders to monitor deadlines and coordinate with the consultant and other parties involved in the reporting process to ensure timely reporting and timely completion of the audit. Management will communicate these responsibilities to new staff as necessary to ensure ongoing compliance and prevent recurrence. Name(s) of the contact person(s) responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: August 2025
Recommendation: We recommend that the City review and update internal controls to ensure that supporting documentation for allowable time charges to grant programs is properly maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Recommendation: We recommend that the City review and update internal controls to ensure that supporting documentation for allowable time charges to grant programs is properly maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management continues to reinforce the policy that requires employees funded by federal grants to document the actual time and effort spent working on those grant activities. Staff continues with the updated timekeeping method for individuals charging partial time to the Housing Choice Voucher (Section 8) program to track actual hours dedicated to the program rather than through budget allocation, and a quarterly certification form is prepared for employees that charge 100% to the Housing Choice Voucher (Section 8) program. Supervisor approvals are documented through the financial system’s electronic workflow. Reports are generated to demonstrate completion. New staff receive training on the payroll approval process to ensure consistent implementation and compliance with procedures. Name(s) of the contact person(s) responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: January 2026
Recommendation: We recommend the City update their controls to ensure that the supervisory quality control HQS inspections are performed in a timely manner and that proper documentation of the annual process and results are maintained. Furthermore, we recommend reperformance of the supervisory quali...
Recommendation: We recommend the City update their controls to ensure that the supervisory quality control HQS inspections are performed in a timely manner and that proper documentation of the annual process and results are maintained. Furthermore, we recommend reperformance of the supervisory quality control HQS inspections for FY24-25. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA updated the administrative plan in 2026. The RBHA has calendared the required monthly days for current and future staff to schedule and conduct quality control inspections. Calendar reminders will alert staff to begin and complete the quality control inspections process. RBHA staff also created a file folder for Quality Control Inspections in the share drive to centralize the quality control inspections details for current and future staff. Within these folders are tracking forms to document that the supervisory inspections that are performed in a timely manner and that proper documentation of the annual process and results are maintained. Name(s) of the contact person(s) responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: December 2025
FA 2025-004 Improve Controls over Special Reporting Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Reporting Significant Deficiency None U.S. Department ...
FA 2025-004 Improve Controls over Special Reporting Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Reporting Significant Deficiency None U.S. Department of Agriculture Georgia Department of Education 10.553 - School Breakfast Program 10.555 - National School Lunch Program 255GA324N1199 (Year: 2025) None identified Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the monthly Claims for Reimbursement process. Corrective Action Plans: The School District will strengthen policies, procedures, and internal controls over the monthly Claims for Reimbursement process to ensure claims are accurate, properly supported, reviewed, and submitted timely. • Review and document procedures for preparing and submitting the monthly DE0106 Claim Data reports, including reconciliation to supporting meal count records. • Require reconciliation of DE0106 claims to the corresponding DE0112 Breakfast and DE0118 Lunch reports prior to submission. • Establish a documented secondary review and approval process for monthly reimbursement claims to verify accuracy, completeness, and allowable expenditures. • Maintain supporting documentation for each claim, including meal count reports, reimbursement calculations, and evidence of review and approval. • Provide training to Child Nutrition and Finance personnel responsible for preparing, reviewing, and submitting reimbursement claims. • Conduct periodic internal reviews of submitted claims to identify and correct errors and endure procedures are consistently followed. Estimated Completion Date: June 30, 2027 Contact Person: Kimberly Harrison Telephone: 912-427-1000 Email: kharrison@wayne.k12.ga.us
FA 2025-003 Improve Controls over Procurement and Suspension and Debarment Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Procurement and Suspension and ...
FA 2025-003 Improve Controls over Procurement and Suspension and Debarment Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Procurement and Suspension and Debarment Material Weakness Material Noncompliance U.S. Department of Agriculture Georgia Department of Education 10.553 - School Breakfast Program 10.555 - National School Lunch Program 255GA324N1199 (Year: 2025) $333,778 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that the School District's procurement and suspension and debarment procedures were followed. Corrective Action Plans: The School District concurs with the finding and will strengthen internal controls to ensure that all expenditures charged to the Child Nutrition Cluster comply with applicable federal procurement and suspension and debarment requirements. • Review and update procurement procedures for federally funded Child Nutrition purchases to ensure compliance with federal, state, and District requirements. • Require documentation of suspension and debarment verification for applicable vendors prior to purchases using federal funds. • Implement a federal procurement checklist to document required quotes, approvals, procurement methods, and vendor eligibility verification. • Provide training to Finance, Purchasing, and Child Nutrition personnel on federal procurement and suspension/debarment requirements. • Conduct periodic reviews of Child Nutrition expenditures to verify that procurement and vendor verification requirements are being followed and properly documented. Estimated Completion Date: June 30, 2027 Contact Person: Kimberly Harrison Telephone: 912-427-1000 Email: kharrison@wayne.k12.ga.us
FA 2025-002 Strengthen Controls over Expenditures Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Activities Allowed or Unallowed Allowable Costs/Cost Pri...
FA 2025-002 Strengthen Controls over Expenditures Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Activities Allowed or Unallowed Allowable Costs/Cost Principles Significant Deficiency Nonmaterial Noncompliance U.S. Department of Agriculture Georgia Department of Education 10.553 - School Breakfast Program 10.555 - National School Lunch Program 255GA324N1199 (Year: 2025) $36,927 Description: A review of employee compensation expenditures and journal entries related to the Child Nutrition Cluster revealed that the School District’s internal control procedures were not operating appropriately to ensure that employee compensation and journal entries were appropriately reviewed, approved, and documented. Corrective Action Plans: The School District will strengthen internal controls to ensure that employee compensation and journal entries charged to the Child Nutrition Cluster are properly reviewed, approved, supported, and documented. • Review and document procedures for processing and allocating employee compensation charged to the Child Nutrition Cluster. • Require appropriate supervisory review and approval of employee compensation, including time and effort documentation, payroll allocations, and related supporting documentation. • Establish a documented review and approval process for journal entries affecting Child Nutrition funds, including verification of account codes, amounts, supporting documentation, and proper authorization. • Provide training to Finance and Child Nutrition personnel on payroll documentation, allowable costs, journal entries, and federal grant requirements. • Conduct periodic reviews of payroll expenditures and journal entries to ensure required approvals and supporting documentation are maintained and any errors are identified and corrected timely. Estimated Completion Date: June 30, 2027 Contact Person: Kimberly Harrison Telephone: 912-427-1000 Email: kharrison@wayne.k12.ga.us
FA 2025-001 Improve Controls over Procurement and Suspension and Debarment Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Procurement and Suspension and ...
FA 2025-001 Improve Controls over Procurement and Suspension and Debarment Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass- Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Procurement and Suspension and Debarment Material Weakness Material Noncompliance U.S. Department of Agriculture Georgia Department of Education 84.027A - Special Education Grants to States 84.173A – Special Education Preschool Grants H027A240073 (Year: 2025), H027A230073 (Year: 2024) H173A240081 (Year: 2025), H173A230081 (Year: 2024) $11,583 Description: A review of expenditures charged to the Special Education Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that the School District's procurement and suspension and debarment procedures were followed. Corrective Action Plans: The School District will strengthen internal controls to ensure that all expenditures charged to the Special Education Cluster (as well as other federal program clusters) comply with applicable federal procurement and suspension and debarment requirements. • Review and update procurement procedures for federally funded purchases to ensure compliance with federal and District requirements. • Require documentation of suspension and debarment verification for applicable vendors prior to purchases using federal funds. • Implement a procurement checklist or verification spreadsheet and process for federal purchases to document required quotes, approvals, procurement methods, and suspension/debarment verification. • Provide training to Finance, Purchasing, and applicable school/district personnel on federal procurement and suspension/debarment requirements. • Conduct periodic reviews of federal expenditures to verify that procurement documentation and vendor eligibility checks are completed and maintained. Estimated Completion Date: June 30, 2027 Contact Person: Kimberly Harrison Telephone: 912-427-1000 Email: kharrison@wayne.k12.ga.us
Management is reviewing and strengthening the Sliding Fee Discount Program (SFDP) to ensure compliance with regulatory and internal requirements. Corrective actions focus on clarifying income verification and documentation standards, enhancing staff training, and implementing periodic monitoring to ...
Management is reviewing and strengthening the Sliding Fee Discount Program (SFDP) to ensure compliance with regulatory and internal requirements. Corrective actions focus on clarifying income verification and documentation standards, enhancing staff training, and implementing periodic monitoring to ensure consistent application of the sliding fee scale. As part of these efforts, the Organization plans to conduct robust and targeted staff training. The training will include all staff members and cover SFDP eligibility, income verification, documentation requirements, and proper application of discounts in alignment with HRSA Program Requirements. Expected outcomes include improved consistency in SFDP application across departments, increased staff understanding of compliance requirements, fewer incomplete or unsupported applications, and stronger documentation and audit readiness. The Organization will monitor closely and supervise the application of the sliding fee scale, and it will set accountability standards for its application.
2025-004 — Corrective action plan. Management agrees with this finding. HOPE will: (1) notify each pass-through entity in writing that the fiscal 2025 reporting package is late and give the expected submission date (by November 6, 2026); (2) coordinate the Federal Audit Clearinghouse submission with...
2025-004 — Corrective action plan. Management agrees with this finding. HOPE will: (1) notify each pass-through entity in writing that the fiscal 2025 reporting package is late and give the expected submission date (by November 6, 2026); (2) coordinate the Federal Audit Clearinghouse submission with the auditor, confirm HOPE’s SAM.gov registration, and designate the CEO as HOPE’s certifying official and the CFO as contact (by November 6, 2026); (3) submit the fiscal 2025 data collection form and reporting package within 30 days of receiving the auditor’s reports, with a target of 10 business days; (4) send the Clearinghouse acceptance confirmation to each pass-through entity within 5 business days of acceptance; (5) adopt a compliance calendar of all federal and pass-through reporting deadlines, with an owner for each and monthly verification by the CEO (by November 30, 2026); (6) amend the Resolution of Audit Findings Protocol to add a single audit timeline ending in Clearinghouse submission by June 30, with pass-through entities notified at least 30 days in advance of any expected delay (by November 30, 2026); and (7) agree on a fiscal 2026 audit timeline with the auditor that ends in submission by June 30, 2027 (by December 31, 2026). Responsible contact person: Benjamin Schutt, Chief Financial Officer.
Corrective Action Plan Finding 2025-002 Criteria: Recipients of federal awards must follow the procurement standards set out at 2 CFR section 200.317 through 200.326. They must use their own documented procurement procedures, which reflect applicable State laws and regulations, provided that the pro...
Corrective Action Plan Finding 2025-002 Criteria: Recipients of federal awards must follow the procurement standards set out at 2 CFR section 200.317 through 200.326. They must use their own documented procurement procedures, which reflect applicable State laws and regulations, provided that the procedures conform to applicable Federal law and the procurement requirements identified in 2 CFR part 200. Recipients “must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price” 2 CFR section 200.318(i). Auditor Recommendation: We recommend the Academy ensure it 1) maintains documentation of the history of procurement and 2) monitors compliance with documentation requirements. Auditee Response/ Corrective Action Plan: The Academy will review its procurement policies and internal controls and ensure timely action is taken when noncompliance is identified. Person Responsible: Tim Stay, CEO Timeline: All future contract solicitations will follow the required procurement standards.
Finding Summary: NNCH did not properly procure three contracts in accordance with applicable procurement requirements and the Organization's procurement policy. Additionally, procedures were not sufficient to ensure that contracts contained all provisions required under Uniform Guidance. Responsible...
Finding Summary: NNCH did not properly procure three contracts in accordance with applicable procurement requirements and the Organization's procurement policy. Additionally, procedures were not sufficient to ensure that contracts contained all provisions required under Uniform Guidance. Responsible Individuals: Matthew Fleming, Executive Director; Jocelyn Kendall-Perez, Deputy Director & CFO Corrective Action Plan: Management acknowledges the finding and has reviewed the circumstances surrounding the contracts identified with the independent auditors. Two of the three contracts identified involved specialized professional services, including a development consultant whose engagement originated prior to NNCH's receipt of the applicable federal funding and a procurement management consultant. Although management considered the specialized nature and circumstances of these engagements when making the contracting decisions, NNCH recognizes that the procurement documentation maintained did not sufficiently demonstrate compliance with the applicable federal procurement requirements. As part of management's review of this finding with the independent auditors, NNCH discussed adopting a more conservative procurement approach for future contracting. Going forward, NNCH intends to evaluate and document procurements with the expectation that federal funding requirements may ultimately apply, even when federal funding is not anticipated at the time the contract is initiated. This approach is intended to provide greater flexibility if a funding source changes during the term of an engagement and to reduce the risk of an existing contract later being determined ineligible for federal reimbursement due to procurement requirements. NNCH will update its procurement procedures and develop a standardized procurement checklist addressing applicable procurement thresholds, required competition, documentation of permissible noncompetitive procurement when applicable, required approvals, suspension and debarment verification, and applicable federal contract provisions. Procurement documentation will be maintained with the applicable contract or project records. NNCH will also review applicable contracts prior to execution to verify that required procurement documentation and contract provisions have been addressed. Staff involved in contracting and procurement will receive guidance regarding the revised procedures and documentation requirements. Anticipated Completion Date: December 31, 2026
The Church agrees with the finding. Going forward, all reimbursement requests will be reviewed and approved by someone independent of the preparer, before submission.
The Church agrees with the finding. Going forward, all reimbursement requests will be reviewed and approved by someone independent of the preparer, before submission.
Condition: For two subrecipients selected, PHIMC maintained executed agreements and performed documented programmatic and fiscal monitoring through administrative site visits. However, PHIMC did not maintain formal, written overarching subrecipient monitoring policies and procedures governing requir...
Condition: For two subrecipients selected, PHIMC maintained executed agreements and performed documented programmatic and fiscal monitoring through administrative site visits. However, PHIMC did not maintain formal, written overarching subrecipient monitoring policies and procedures governing required federal award information, subrecipient risk assessments, risk-responsive monitoring, single audit applicability determinations, follow-up of identified matters, and supervisory review. In addition: • The agreements did not contain all required federal award information, and PHIMC did not provide evidence that the omitted information was otherwise communicated; • PHIMC did not perform or document a risk assessment supporting the nature and extent of monitoring; and • PHIMC did not retain documentation supporting its determination that the subrecipients were not subject to Single Audit requirements Management Response: Management concurs with the finding. Corrective Action Taken or Planned: Management will develop, document, and implement comprehensive written subrecipient monitoring policies and procedures. The procedures will require PHIMC to: (1) include all required federal award information in each subaward agreement or related award document; (2) complete and retain a documented risk assessment for each subrecipient and tailor monitoring procedures to the assessed risk; (3) document each subrecipient’s Single Audit applicability determination and verify completion when applicable; (4) document follow-up and resolution of matters identified through monitoring; and (5) perform and document a supervisory review confirming that all required procedures have been completed. Management will also update its standard subaward agreement and implement standardized monitoring and review checklists. Anticipated Date of Completion: December 31, 2026 Name of Contact Person Responsible for Corrective Action: Karen Reitan, President & Chief Executive Officer
Condition: PHIMC did not submit its 2025 Data Collection Form and single audit reporting package to the Federal Audit Clearinghouse before the deadline of September 30, 2026. In addition, PHIMC's Consolidated Year End Financial Report (CYEFR) required by the Grant Accountability and Transparency Act...
Condition: PHIMC did not submit its 2025 Data Collection Form and single audit reporting package to the Federal Audit Clearinghouse before the deadline of September 30, 2026. In addition, PHIMC's Consolidated Year End Financial Report (CYEFR) required by the Grant Accountability and Transparency Act was also submitted late. Management Response: Management concurs with the finding. Corrective Action Taken or Planned: Management will establish and maintain a compliance reporting calendar that identifies the applicable due dates, responsible personnel, required review and approval, and submission status for the Data Collection Form, Single Audit reporting package, and CYEFR. Management will monitor the calendar throughout the reporting process and provide sufficient time for final review and submission. PHIMC plans to submit the December 31, 2026 Data Collection Form and Single Audit reporting package to the Federal Audit Clearinghouse, and the related CYEFR to the appropriate state agency, by their respective applicable deadlines. Anticipated Date of Completion: September 30, 2027, or earlier if required under the applicable federal submission deadline. Name of Contact Person Responsible for Corrective Action: Karen Reitan, President & Chief Executive Officer.
2025-007 Sliding Fee Discount Program Administration The program policy will be reviewed and enforced across all sites with the help of Practice leaders and operational oversight. This will also be under the new Revenue Cycle Manager position who will be hired on or before January 31, 2027
2025-007 Sliding Fee Discount Program Administration The program policy will be reviewed and enforced across all sites with the help of Practice leaders and operational oversight. This will also be under the new Revenue Cycle Manager position who will be hired on or before January 31, 2027
On July 23, 2026, the Corporation paid in full its outstanding Paycheck Protection Program (PPP) loan totaling $52,623. This finding has been resolved
On July 23, 2026, the Corporation paid in full its outstanding Paycheck Protection Program (PPP) loan totaling $52,623. This finding has been resolved
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