Corrective Action Plans

Finding 4060 (2023-002)

None 2023

NH

HUD Housing Programs Internal Control / Segregation of Duties

Plan: We will continue to hire and train additional staff to fill the staffing shortages. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael ...

Plan: We will continue to hire and train additional staff to fill the staffing shortages. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6375

Finding 4059 (2023-001)

None 2023

Pembroke Housing for the Elderly, Inc.

NH

HUD Housing Programs Internal Control / Segregation of Duties

Plan: A system will be put in place requiring more than one individual to have an EIV license and ensure the license does not lapse. Anticipated Completion: December 31, 2023 (ongoing) Conta...

Plan: A system will be put in place requiring more than one individual to have an EIV license and ensure the license does not lapse. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6375

Finding 4052 (2023-005)

Significant Deficiency 2023

Newbury Elderly Housing, Inc.

NH

Allowable Costs / Cost Principles Reporting

Plan: Job duties will be documented for each position and a policy will be implemented to ensure all time sheets detail the duties performed. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6374

Finding 4050 (2023-004)

Significant Deficiency 2023

Newbury Elderly Housing, Inc.

NH

HUD Housing Programs Internal Control / Segregation of Duties

Plan: A procedure was implemented to ensure that the Project timely changes the certifier on forms when applicable. Anticipated Completion: June 30, 2023 ...

Plan: A procedure was implemented to ensure that the Project timely changes the certifier on forms when applicable. Anticipated Completion: June 30, 2023 Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6374

Finding 4048 (2023-003)

None 2023

Newbury Elderly Housing, Inc.

NH

Subrecipient Monitoring Cash Management

Plan: The Housing Director will monitor all major maintenance projects to ensure they are completed in a timely manner even with turnover at the project level. Anticipated Completion: December 31, 2023 (ongoing) ...

Plan: The Housing Director will monitor all major maintenance projects to ensure they are completed in a timely manner even with turnover at the project level. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6374

Finding 4045 (2023-002)

None 2023

Newbury Elderly Housing, Inc.

NH

Plan: We will continue to hire and train additional staff to fill the staffing shortages. And ensure that recertification paperwork is filed correctly and in a timely manner. Anticipated Completion: December 31, 2023 (ongoing) ...

Plan: We will continue to hire and train additional staff to fill the staffing shortages. And ensure that recertification paperwork is filed correctly and in a timely manner. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6374

Finding 4044 (2023-001)

None 2023

Newbury Elderly Housing, Inc.

NH

HUD Housing Programs Internal Control / Segregation of Duties

Plan: A system will be put in place requiring more than one individual to have an EIV license and ensure the license does not lapse. Anticipated Completion: December 31, 2023 (ongoing) Conta...

Plan: A system will be put in place requiring more than one individual to have an EIV license and ensure the license does not lapse. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6374

Finding 4042 (2023-002)

Significant Deficiency 2023

Municipality of Quebradillas

PR

Subrecipient Monitoring Reporting § 200.328

The Municipality established internal control to maintain schedule of the due date reports in order to avoid this situation.

View Audit 6364

Finding 4035 (2023-001)

None 2023

Remington College

TX

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Finding 2023-001 A. Comments on Findings and Recommendations: We agree with the finding and recommendation. B. Actions Taken or Planned: The Institution has reviewed the details of the findings and determined the errors to be due to human error. For student #13, the R2T4 in question was a refund...

Finding 2023-001 A. Comments on Findings and Recommendations: We agree with the finding and recommendation. B. Actions Taken or Planned: The Institution has reviewed the details of the findings and determined the errors to be due to human error. For student #13, the R2T4 in question was a refund which was returned on June 15, 2023, in the amount of $595 to the 2022-2023 Federal Pell Grant Program funds. The Institution should have recalculated the Federal Pell Grant funds to include in the R2T4 calculation. The Institution used $1,261 as Federal Pell disbursed, when we should have only used $420 (due to the student being less than ½ time). After recalculating the Federal Pell, the Institution should have returned $214 to 2022-2023 Federal Pell Grant program funds. This resulted in an under return of $460 in 2022-2023 Federal Pell program funds. In addition, the Institution used an incorrect number of days in the payment period in the R2T4 calculation, resulting in an incorrect percentage of aid earned. For student #AR1, the R2T4 in question was a refund which was returned on May 31, 2023, in the amount of $9 in 2022-2023 Federal Subsidized Direct Loan Program funds. The $9 was in the amount of R2T4 funds which was due to the student and not required to be returned by the Institution. The Institution did not have authorization from the student to return funds to the Federal Subsidized Direct Loan Program. This resulted in an over return of $9. For student #AR15, the R2T4 in question was a refund which was returned on October 24, 2022, in the amount of $929 to the 2022-2023 Federal Pell Grant Program funds. The Institution should have returned $1,431, which resulted in an under return of $502. The Institution used an incorrect number of days in the payment period in the R2T4 calculation, resulting in an incorrect percentage of aid earned. Subsequent to the audit, the Institution returned $962 to the Federal Pell Grant Program funds on behalf of student #13 and student #AR15. The Institution has planned the following immediate solutions to ensure accuracy for R2T4 calculations. • Share Corrective Action Plan (CAP) with accountable staff. • Create a scheduled hours chart for all programs to address the incorrect number of days being calculated in a payment period. Additionally, the Institution will standardize the usage of the automated calculations within the Institution’s Student Information System (Anthology) to help minimize potential human errors within our processes. • Evaluate and update R2T4 policies and procedures as necessary to incorporate these solutions. • Train staff on R2T4 calculations as well as conduct ongoing training on an annual basis. o This will also incorporate training on the Institution’s R2T4 policies, including covering the requirement that student files should be reviewed for appropriate student authorizations as well as the full-time/part-time status of a student. • Re-train staff on the Institution’s R2T4 peer review process. • Establish target dates to review CAP effectiveness. o The Institution will conduct a monthly review of the CAP’s effectiveness for the first six months after implementation of the CAP and then will conduct periodic reviews of the CAP thereafter.

View Audit 6351 Questioned Costs: $1

Finding 4030 (2023-001)

Significant Deficiency 2023

Independent School District No. 882

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties School Nutrition Programs

Procurement Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster CFDA Number: 10.553, 10.555, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0882-000 Award Period: July 1, 2022 – June 30, 2023 Type of Finding: • ...

Procurement Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster CFDA Number: 10.553, 10.555, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0882-000 Award Period: July 1, 2022 – June 30, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance and Other Matters CORRECTIVE ACTION PLAN (CAP): Recommendation: It is recommended that the District implement procedures and controls to ensure proper procurement procedures are being followed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure proper procurement procedures are being followed. Official Responsible for Ensuring CAP: Tina Burkholder, Director of Business Services. Planned Completion Date for CAP: June 30, 2024.

View Audit 6348

Finding 4028 (2023-005)

Significant Deficiency 2023

Shepherd Public School District

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance § 200.308 § 200.309

Finding Number 2023-005 — Significant Deficiency in Internal Control/Non-Compliance — Appropriate Expense Period of Covid 19-ESSER II 23b — Credit Recovery Condition: During expense testing of ESSER funds, a journal entry that reclassed the cost of Edmentum, program licenses for Plato courses, had e...

Finding Number 2023-005 — Significant Deficiency in Internal Control/Non-Compliance — Appropriate Expense Period of Covid 19-ESSER II 23b — Credit Recovery Condition: During expense testing of ESSER funds, a journal entry that reclassed the cost of Edmentum, program licenses for Plato courses, had expensed the entire annual license fee. The period for eligible expenditures did not begin until October 1, 2022. This journal entry expensed the full cost of the invoice, $11,914.50, and the district did not prorate the costs to include only those expenses from October 1, 2022 through June 30, 2023. The District did not adhere to the proper period for expenditures. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop a summary of all federal grants. This summary will detail the fiscal year it is associated with but more importantly, it will provide the proper period of eligible expenditures for each federal funding source. This summary may be used and readily available at the time approvals are granted for expenditures. If an expense does not fall within the eligible time period, the expense can be rejected by the approver. This summary will be shared with all administrators and staff. In addition, the process for reclass journal entries will also include a pause to check that each invoice associated with a federal grant, is falling within the proper period of expenditures. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

View Audit 6347

Finding 4027 (2023-006)

Significant Deficiency 2023

Shepherd Public School District

MI

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding Number 2023-006 — Significant Deficiency in Internal Control — Covid 19-ESSER II 23b-Summer School and ESSER II-98C - Approval Process Condition: During expense testing of ESSER funds, a July 2022 expenditure for $24.95, payable to BMO, and an August 2022 invoice for $10,167, payable to IXL ...

Finding Number 2023-006 — Significant Deficiency in Internal Control — Covid 19-ESSER II 23b-Summer School and ESSER II-98C - Approval Process Condition: During expense testing of ESSER funds, a July 2022 expenditure for $24.95, payable to BMO, and an August 2022 invoice for $10,167, payable to IXL for math software licenses, were not approved by the Director of Business Services. During this time, the Director of Business Services position was vacant. Proper internal control procedures would ensure a proper approval process, for any position that is temporarily vacant. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop an approval process workflow that would temporarily utilize another administrator for approvals in Munis if any key position is vacant. The district has two administrators per building. The administrators will have the other building administrator act as approver for that building in the event an administrative position is vacant. If both principal positions are vacant, an administrator in another building will be integrated into the approval process for the building with no administrator. At Central Office, the next key position for approvals would be Trina Smith, the Accounts Payable/Accounts Receivable Accountant. If this position is vacant, the llRlPayroll Accountant will assume those approval duties. The final step of approval is the Director of Business Services to approve items before the AP/AR position can process any items. These items include invoices, requisitions, purchase orders, payroll related items and journal entries. In the event the Director of Business Services position is vacant, the District Superintendent of Schools will be the final approver. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

View Audit 6347

Finding 4026 (2023-004)

Significant Deficiency 2023

Shepherd Public School District

MI

Allowable Costs / Cost Principles § 200.402

Finding Number 2023-004 — Significant Deficiency in Internal Control/Non-Compliance — Covid 19-ESSER II - Approved Expenditures Condition: During expense testing of ESSER funds, a final invoice for a sound system project in Shepherd Middle School was not detailed in the approved grant application. T...

Finding Number 2023-004 — Significant Deficiency in Internal Control/Non-Compliance — Covid 19-ESSER II - Approved Expenditures Condition: During expense testing of ESSER funds, a final invoice for a sound system project in Shepherd Middle School was not detailed in the approved grant application. The expenditure was for $4,010 but the total cost of the project was $20,050. The bulk of the project cost, $16,040, was expended during 2021-2022. The sound system was not an allowable cost based on not being in the original grant application. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop an approval process that requires the Director of Business Services to review approved grant application prior to approving any federal grant expenditure. The Director of Federal Programs and the Director of Business Services will meet monthly to review federal grants, expenditures in the near future and discuss/review proper assignment of expenses to the specific grants and general ledger function codes. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

View Audit 6347

Finding 4022 (2023-003)

Material Weakness 2023

Shepherd Public School District

MI

Cash Management School Nutrition Programs Material Weakness

Finding Number 2023-003 — Excess in Food Service Fund — Repeat Finding - Material Weakness in Internal Control/Noncompliance — Special Tests and Provisions Condition: As of year-end, June 30, 2023, the district had a fund balance in the food service fund in excess of three months operating expenses ...

Finding Number 2023-003 — Excess in Food Service Fund — Repeat Finding - Material Weakness in Internal Control/Noncompliance — Special Tests and Provisions Condition: As of year-end, June 30, 2023, the district had a fund balance in the food service fund in excess of three months operating expenses by approximately $ 268,411. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: June 30, 2024 Corrective Action: The district has filed a spend down plan with the State of Michigan. This plan includes increasing labor costs for the operation of a kitchen at Winn Elementary School. Additionally, the district will purchase much needed new equipment. Sincerely Carl Seiter Director of Business Services Shepherd Public Schools

View Audit 6347

Finding 4021 (2023-004)

None 2023

Drew Memorial Hospital, Inc. D/b/a Drew Memorial Health System

AR

Questioned Costs Allowable Costs / Cost Principles Reporting

Responsible Party: Melodie Colwell Finding 2023-004 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on th...

Responsible Party: Melodie Colwell Finding 2023-004 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management considers the expenditures reported to be in compliance with program regulations. Management agrees with the finding that additional supporting documentation should be retained. Going forward, for subsequent reporting periods related to the Provider Relief Fund and American Rescue Plan Rural Distribution management will implement controls to ensure all underlying support related to expenses is documented and retained. Estimated completion and implementation date for the above-mentioned corrective action plan is March 31, 2024.

View Audit 6331 Questioned Costs: $1

Finding 4020 (2023-003)

Material Weakness 2023

Drew Memorial Hospital, Inc. D/b/a Drew Memorial Health System

AR

Questioned Costs Allowable Costs / Cost Principles Reporting

Responsible Party: Melodie Colwell Finding 2023-003 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that were reimbursed through other funding sources and reported expenditures that did not have supporting documentation showing expenditures were ...

Responsible Party: Melodie Colwell Finding 2023-003 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that were reimbursed through other funding sources and reported expenditures that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management agrees with the finding that expenses should be reimbursed by only one source. Management believes that while certain expenses were reported that were reimbursed by other funding sources they have additional allowable expenditures that could have been reported. Going forward, for subsequent reporting periods related to the Provider Relief Fund and American Rescue Plan Rural Distribution management will allocate expenditures as required, and will ensure expenses are reimbursed in accordance with current guidance. Estimated completion and implementation date for the above-mentioned corrective action plan is March 31, 2024.

View Audit 6331 Questioned Costs: $1

Finding 4019 (2023-002)

Significant Deficiency 2023

Drew Memorial Hospital, Inc. D/b/a Drew Memorial Health System

AR

Reporting Internal Control / Segregation of Duties

Responsible Party: Melodie Coldwell Finding 2023-002 The Hospital submitted the provider relief fund report without proper review. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Manag...

Responsible Party: Melodie Coldwell Finding 2023-002 The Hospital submitted the provider relief fund report without proper review. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management will take action to implement controls around the provider relief fund report for proper completion and review. Estimated completion date for the above-mentioned corrective action is March 31, 2024.

View Audit 6331

Finding 4004 (2023-001)

Significant Deficiency 2023

Augustana University Association

SD

Student Financial Aid Reporting Significant Deficiency

Department of Education Augustana University respectfully submits the following corrective action plan for the year ended July 31, 2023. Audit period: August 01, 2022 – July 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consis...

Department of Education Augustana University respectfully submits the following corrective action plan for the year ended July 31, 2023. Audit period: August 01, 2022 – July 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no findings in the current year that require corrective action plan. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF EDUCATION 2023-001 Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.007, 84.0033, 84.063, 84.268, 84.379 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have implemented a secondary compliance check of student withdrawal dates. As the Registrar Assistant is notified of student withdrawals, the ‘Leave Date’ is entered into the Jenzabar/CX system. On a weekly basis, the Assistant Registrar will double check the withdrawal notice with the date in Jenzabar/CX. Performing this double check on a weekly basis should catch any incorrectly entered dates before they are transmitted to NSLDS. If an incorrectly entered date is found, the Assistant Registrar will notify the Director of Financial Aid, who will check NSLDS to further ensure the date has not been incorrectly included in enrollment reporting. Name(s) of the contact person(s) responsible for corrective action: Joni Krueger Planned completion date for corrective action plan: immediately / already implemented If the Department of Education has questions regarding this plan, please call Joni Krueger at 605.274.4121.

View Audit 6326

Finding 4000 (2023-001)

Material Weakness 2023

Granite School District

UT

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions § 200.326

The District will review, update and train staff on the processes and internal controls related to construction contracts to ensure compliance with the Wage Rate Requirements as published in 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted C...

The District will review, update and train staff on the processes and internal controls related to construction contracts to ensure compliance with the Wage Rate Requirements as published in 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction when applicable.

View Audit 6311

Finding 3998 (2023-001)

Significant Deficiency 2023

South Dakota Housing Development Authority

SD

Allowable Costs / Cost Principles Eligibility Significant Deficiency

Federal Agency Name: U.S. Department of Treasury Program Name and FALN #: FALN # 21.023 COVID-19 Emergency Rental Assistance Program (ERA) Finding Summary: One homebuyer payment was allocated to ERA instead of the Homeownership Assistance Fund (HAF). Homebuyers are not eligible for assistance under ...

Federal Agency Name: U.S. Department of Treasury Program Name and FALN #: FALN # 21.023 COVID-19 Emergency Rental Assistance Program (ERA) Finding Summary: One homebuyer payment was allocated to ERA instead of the Homeownership Assistance Fund (HAF). Homebuyers are not eligible for assistance under ERA. Responsible Individuals: Chas Olson - Executive Director and Bridgette Loesch, SD Cares Housing Assistance Program Manager Corrective Action Plan: We have made the adjustment to the correct program once we were made aware of the issue by the auditors. We will carefully review the program sheets prior to submitting to accounting to ensure they are allocated to the correct program. Anticipated Completion Date: September 30, 2023

View Audit 6305

Finding 3991 (2023-002)

Significant Deficiency 2023

Crockett Independent School District

TX

Corrective Action Plan: The District will monitor and take corrective action moving forward to ensure no future occurrences.

View Audit 6289

Finding 3990 (2023-001)

Significant Deficiency 2023

Crockett Independent School District

TX

Corrective Action Plan: The District will take will take immediate corrective action for the employees effected from the audit to update the documentation. The District will institute procedures to do better review of the time and effort reports moving forward and avoid rolling forward the forms fro...

Corrective Action Plan: The District will take will take immediate corrective action for the employees effected from the audit to update the documentation. The District will institute procedures to do better review of the time and effort reports moving forward and avoid rolling forward the forms from the prior year.

View Audit 6289

Finding 3985 (2023-001)

Significant Deficiency 2023

Carleton College

MN

Student Financial Aid Reporting Significant Deficiency

Department of Education Carleton College respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 – June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently...

Department of Education Carleton College respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 01, 2022 – June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no findings in the current year that require corrective action plan. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF EDUCATION 2023-001 Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.007, 84.0033, 84.063, 84.268 Recommendation: We recommend the Institute review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have developed additional validation steps to confirm that the status of every student who has completed their program and graduated is accurately reflected at both the National Student Clearinghouse and at NSLDS. Name(s) of the contact person(s) responsible for corrective action: Theresa Rodriguez Planned completion date for corrective action plan: 9/30/2023 If the Department of Education has questions regarding this plan, please call Theresa Rodriguez, Registar at 507-222-4290.

View Audit 6287

Finding 3983 (2023-001)

None 2023

Carolina College of Biblical Studies

NC

Student Financial Aid Cash Management Reporting

The Vice President of Finance corrected the disbursement dates for the students in question in September 2023. Going forward, the Student Financial Aid Office and Business Office will coordinate the drawdown of funds, reporting to COD, and posting to student accounts. The personnel of the College un...

The Vice President of Finance corrected the disbursement dates for the students in question in September 2023. Going forward, the Student Financial Aid Office and Business Office will coordinate the drawdown of funds, reporting to COD, and posting to student accounts. The personnel of the College understands that while on the cash advance method to disburse funds, they have three business days from the date the funds are received to post the funds to the student accounts. However, the disbursement date on the student account and in COD still must agree. Anticipated Completion Date: The corrective action was completed in September 2023. Contact Person: Stephanie Dickerson, Registrar/Financial Aid 910-323-5614

View Audit 6283

Finding 3982 (2023-002)

Significant Deficiency 2023

Chase Brexton Health Services, Inc.

MD

Eligibility Internal Control / Segregation of Duties

The operations team, under the guidance of Chief Operating and Quality Officer, will evaluate and develop a sustainable annual review process for all Chase Brexton patients qualifying for Ryan White services. This will ensure that all persons regardless of need will be evaluated annually or documen...

The operations team, under the guidance of Chief Operating and Quality Officer, will evaluate and develop a sustainable annual review process for all Chase Brexton patients qualifying for Ryan White services. This will ensure that all persons regardless of need will be evaluated annually or documented that they no longer quality for services under the Ryan White Part A program. Chase Brexton will begin the process of evaluating and developing these protocols immediately.

View Audit 6274

Corrective Action Plans

Filters