Corrective Action Plans

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The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
CCAA obtained nonfederal funds for expenditures exceeding the grant contract amount. CCAA is in the process of analyzing all grant expenditures and formulating plans to ensure expenditures do not exceed the annual contract amount.
CCAA obtained nonfederal funds for expenditures exceeding the grant contract amount. CCAA is in the process of analyzing all grant expenditures and formulating plans to ensure expenditures do not exceed the annual contract amount.
Condition: Management did not renew their property insurance which expired 10/27/25 until new coverage was executed effective date 7/8/26. Corrective Action: We obtained property/liability insurance for the period 7/8/26-10/27/27 as of 7/10/26. The organization will maintain a centralized insurance ...
Condition: Management did not renew their property insurance which expired 10/27/25 until new coverage was executed effective date 7/8/26. Corrective Action: We obtained property/liability insurance for the period 7/8/26-10/27/27 as of 7/10/26. The organization will maintain a centralized insurance and compliance calendar containing policy expiration dates, premium due dates, responsible parties, broker contact information and required documentation. Management will verify active insurance coverage monthly and retain current policies, certificates of insurance, invoices, and proof of payment in a centralized electronic file. The Finance Committee will review insurance coverage as part of its regular financial oversight and report to the full Board of Directors at the monthly meeting and no later than 90 days before policy expiration so that immediate action can take place. Person Responsible: Board President Date of Corrective Action: 7/10/26
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a p...
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.
Finding No. 2026-001: During testing of allowable costs for Major Program 93.912, one instance was identified in which payroll benefit costs charged to the federal award were overstated by $383 due to an error in the calculation of payroll-related benefits associated with an individual employee. As ...
Finding No. 2026-001: During testing of allowable costs for Major Program 93.912, one instance was identified in which payroll benefit costs charged to the federal award were overstated by $383 due to an error in the calculation of payroll-related benefits associated with an individual employee. As a result of the exception identified during audit testing, we performed additional procedures over the affected population and determined that an incorrect payroll base had been used in calculating benefit allocations charged to federal awards for certain employees for which payroll and benefits are allocated to federal programs. We identified unsupported payroll benefit costs and indirect costs charged to the following federal programs: Program 93.912-$15,046; Program 93.387-$1,901; and Program 93.889-$29,718, for total questioned costs of $46,665. We intend to return these funds to the grantor agencies. Accordingly, the $46,665 of unsupported costs was removed from expenditures reported on the Schedule of Expenditures of Federal Awards, and no known questioned costs are reported in the Schedule of Findings and Questioned Costs. Corrective Actions Planned: A simplified report has been identified that will reduce the risk of calculation errors. This report will be used for all future calculations related to payroll-related benefits for grants. Responsible Party: Karla Dillow, Assistant Director of Accounting Target Completion Date: March 31, 2027
2026-001 Public Housing Capital Fund Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to Procurement, Suspension and Debarment. Action Taken: Management will implement policies and procedures to ensure the Commission is...
2026-001 Public Housing Capital Fund Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to Procurement, Suspension and Debarment. Action Taken: Management will implement policies and procedures to ensure the Commission is in compliance with all grant requirements pertaining to the Public Housing Capital Grant. Anticipated Completion Date of Action: October 31, 2026
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. These advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unawa...
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. These advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware that such an advance was not permitted to be made. Kane Financial Services was also unaware. The plan to correct it includes the following action steps:  Seeking approval from HUD for the $2.7M advance.  If the advance is not approved, then the repayment will occur by the organizations over an 18 month period beginning in October 2025. It is understood that such advances will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: SShain@kanefs.com Phone: 561-223-4161
To Whom it May Concern, Orlando Rehabilitation Group, Inc. issued $8.0 million in grants during the fiscal year ending March 31, 2026. These grants were made to unaffiliated not-for-profit healthcare organizations. Orlando Rehabilitation Group, Inc., was unaware that these grants were not permitted ...
To Whom it May Concern, Orlando Rehabilitation Group, Inc. issued $8.0 million in grants during the fiscal year ending March 31, 2026. These grants were made to unaffiliated not-for-profit healthcare organizations. Orlando Rehabilitation Group, Inc., was unaware that these grants were not permitted to be made according to the structure of their HUD Mortgage. Kane Financial Services was also unaware. The plan to correct it includes the following action steps:  Seeking approval from HUD for the $8.0M in grants.  If the grant is not approved, then the Orlando Rehabilitation Group, Inc., will attempt to facilitate a re-payment plan over an extended period of time with the recipients of the grants. It is understood that such grants will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: SShain@kanefs.com Phone: 561-223-4161
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer has searched the state procurement office webpage to check if any vendor for a federal project i...
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Village will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2027 fiscal year. The plan for adherence is the Council will review implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2027 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Finding 2026-001 – Internal Control over Financial Reporting – Allowable Costs U.S. Department of Treasury Passed Through the County of Erie COVID-19: Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 Allowable Costs Contact Person Responsible for Corrective Action: Name: Tammi Michali T...
Finding 2026-001 – Internal Control over Financial Reporting – Allowable Costs U.S. Department of Treasury Passed Through the County of Erie COVID-19: Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 Allowable Costs Contact Person Responsible for Corrective Action: Name: Tammi Michali Title: Office Manager Phone/Email: 814-897-2690 / tmichali@ecgra.org Auditor’s Recommendation: The auditors recommend that management implement procedures to ensure all disbursements charged to federal programs are formally reviewed and approved by the Board, or by a properly designated approver, and that such approval is evidenced in writing and maintained with the supporting disbursement documentation. Management should also implement a monitoring procedure to identify any disbursements processed without timely approval and ensure corrective action is taken. Corrective Action Plan: A resolution was passed by the Erie County Gaming Revenue Authority’s Board of Directors affirming their consent to disburse funds for Round 2 of the Educator Retention Awards. The Board was informed by the executive director that this was a clerical oversight as the action to fund Round 2 had been discussed and was given verbal approval at previous Strategic Planning meetings. Anticipated Completion Date: Corrective Action Plan was completed on May 21, 2026
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2026 Estimated Completion Date: June 2026 Finding #2026-001 – Statement of Condition Patients did not receive the proper sliding fee ad...
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2026 Estimated Completion Date: June 2026 Finding #2026-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding, and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Coordination with Revenue Cycle Management has occurred to ensure awareness across teams. Office Managers review all new sliding fee applications on a monthly basis to ensure accuracy, and the Billing Manager conducts quarterly audits of sliding fee claims to ensure adjustments are entered correctly by the billing department. The Organization also continues to provide staff training for all individuals involved in the sliding fee application process. Management has instructed all outsourced billers not to modify sliding fee adjustments; any required changes must be handled by in-house billing staff. Additionally, sliding fee adjustments auto posted in error will be removed. Management is also working with IT to restrict system access for outsourced users to prevent unauthorized adjustments. Additionally, IT will implement a scheduled monthly audit report to identify improper adjustments and monitor user activity.
Management has reviewed the audit finding and acknowledges the allegation related to improper administration of the applicant wait list. The former project manager is no longer with the Project, and management responsibilities have been reassigned. Management plans to review wait list procedures, st...
Management has reviewed the audit finding and acknowledges the allegation related to improper administration of the applicant wait list. The former project manager is no longer with the Project, and management responsibilities have been reassigned. Management plans to review wait list procedures, strengthen oversight and documentation requirements, and implement additional controls to ensure applicants are processed in accordance with established policies and applicable program requirements.
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discounts to certain patients who visited the Organization during the year ended March 31, 2026. In addition, sliding fee applications were not maintained for all patients who received sliding fee disco...
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discounts to certain patients who visited the Organization during the year ended March 31, 2026. In addition, sliding fee applications were not maintained for all patients who received sliding fee discounts. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2026-001, proper training will be given to employees and sliding fee applications and discounts will be reviewed by a supervisor on a monthly basis to ensure compliance with the sliding fee policy. The Organization will also establish procedures to ensure that sliding fee applications are maintained in accordance with the Organization’s policies.
Management agrees with the recommendation and will ensure staff are trained and that recertifications are completed and signed within the required timeframe. A new Community Manager was hired in January 2026 and has been trained on the certifications process guidelines and its importance. The Compli...
Management agrees with the recommendation and will ensure staff are trained and that recertifications are completed and signed within the required timeframe. A new Community Manager was hired in January 2026 and has been trained on the certifications process guidelines and its importance. The Compliance Department will continue to review and monitor timely completion of certifications.
Finding Number: 2026-002 Planned Corrective Action: To ensure compliance with federal reporting standards, the Health Center will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of th...
Finding Number: 2026-002 Planned Corrective Action: To ensure compliance with federal reporting standards, the Health Center will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Additionally, the Health Center will implement policies and procedures surrounding file retention of the underlying data that supports federal reports submitted. Anticipated Completion Date: 1/31/2027 Responsible Contact Person: Braden Miller, Chief Financial Officer
The issue was administrative rather than financial, and the Project is making extra payments to fully fund the replacement reserve balance.
The issue was administrative rather than financial, and the Project is making extra payments to fully fund the replacement reserve balance.
Name of auditee: Anchor Community, Inc. HUD auditee identification number: 101-HD029 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended March 31, 2026 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Telephone number: 901-435-7764 Curren...
Name of auditee: Anchor Community, Inc. HUD auditee identification number: 101-HD029 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended March 31, 2026 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Telephone number: 901-435-7764 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2026-001: At March 31, 2026, the Corporation's reserve for replacements fund was not invested in an interest-bearing account. Comments on the Finding and Each Recommendation: The Agent should transfer the reserve for replacements fund into an interest-bearing account. Action(s) taken or planned on the finding: Agreed. The Agent concurs with the finding and auditor's recommendation.
Recommendation: The Center should develop policies and procedures to help ensure pay rates are consistent with supporting employee agreements or other management-approved documentation. Corrective Action Taken: 1. Immediate Review and Correction Upon identification of the finding, the Center conduct...
Recommendation: The Center should develop policies and procedures to help ensure pay rates are consistent with supporting employee agreements or other management-approved documentation. Corrective Action Taken: 1. Immediate Review and Correction Upon identification of the finding, the Center conducted a comprehensive internal audit of pay rates for all employees hired from January 1, 2025, to the present. Any discrepancies identified during this review were promptly corrected to ensure alignment with approved documentation. 2. Staff Training Targeted training will be provided to all Human Resources and Payroll staff. This training will emphasize: The importance of accuracy in data entry and the use of self-review as a quality control tool; Accountability at both the individual and team levels for maintaining complete and accurate payroll data; and Proper preparation and retention of documentation supporting initial payroll entries and any subsequent changes. 3. Policy and Procedure Review The Center has performed a comprehensive review of its internal policies and procedures to: Ensure clear delineation of roles and responsibilities across hiring, onboarding, and payroll processes; and Provide detailed guidance on required documentation to support each step in these processes. 4. Double-Verification Process Management has reinforced a culture of shared accountability by implementing a doubleverification process. This includes: Requiring staff to review and confirm the accuracy of their own work prior to submission; and Requiring receiving staff to independently verify information and resolve any discrepancies before proceeding with further processing. 5. Continued Monitoring In addition to standard bi-weekly payroll reviews conducted by management, the Center will implement quarterly payroll system audits. These audits will verify that all payroll changes are accurate, properly documented, and supported by appropriate approvals.
Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications on a timely basis. Corrective Action Taken: 1. Immediate Review and C...
Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications on a timely basis. Corrective Action Taken: 1. Immediate Review and Correction Upon determination of the finding, we conducted a full review of the affected patient account. 2. Staff Training All Outreach and Eligibility staff have received refresher training on the proper application of the sliding fee scale, including income verification processes and documentation standards. This training now occurs as part of onboarding and annually thereafter. 3. Policy and Procedure Review We reviewed our internal policies and procedures to ensure clear guidance on income documentation requirements, allowable income sources, and how to properly apply the sliding scale. 4. Double-Verification Process A second-level review has been instituted for all new patient applications and renewals involving sliding fee scale determinations. This ensures that income is correctly assessed, and the appropriate fee level is applied before any charges are finalized. 5. Audit and Monitoring A quarterly internal audit process has been implemented to review a random sample of sliding fee scale determinations for accuracy. Findings from these audits will be tracked, and any trends will be addressed through targeted training or process changes. The corrective actions implemented in the prior year were maintained consistently throughout the current audit period. Based on our evaluation, the processes put in place were operating effectively as designed. The issue identified this year stemmed from front office personnel having access to modify SFS assignments after they had already been appropriately verified and assigned. This access created the opportunity for adjustments outside of the established control process. While the prior corrective actions were effective, we have identified the need for an additional control enhancement. Accordingly, an immediate control has been implemented (see item 6 below) to further restrict access and prevent unauthorized modifications. 6. EMR Restriction As a result of the additional finding identified in 2026, UCHC’s IT Department access to SFS assignments and modifications within the EHR will be restricted exclusively to the Eligibility Team. No other personnel will be permitted to make changes to SFS assignments. All requests for adjustments must be submitted to the Eligibility Team, which will be responsible for thoroughly reviewing and validating each request prior to implementing any changes.
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 & Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization update its procurement policy to be in lin...
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 & Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization update its procurement policy to be in line with the federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will update the Procurement and Purchasing Policy and Procedure to include a Small and Micro-Purchase Threshold and the BABA requirements. The Organization will have this policy and procedure update completed by July 13, 2026.
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the gr...
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has updated the grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. As part of this update management has reassigned responsibilities for various grants to ensure the process is followed.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of this issue and meets regularly to discuss the workflows identified to minimize this issue until the vendor has implemented an interface to resolve this issue. The Organization has procedures in place to address the internal controls related to determining, recording, and monitoring the sliding fee process. The goal is to ensure that the appropriate sliding fee rates/categories are utilized for each encounter for each patient. The Organization has been working with the electronic health record vendor to interface the medical and dental components of the system to ensure the information is flowing across both components of the application. The sliding fee scale information is housed in the medical component of the system and does not consistently flow to the dental component of the system. The tentative go live date for this interface is scheduled for September 2026. Until then the team will continue to assess all dental sliding fee scale patients accounts manually to ensure accurate sliding fee rates/categories are utilized for each sliding fee encounter/patient.
Management agrees with the finding and will put processes and controls in place to verify timely deposits in the future. The required deposit of $4,477 was made in July 2025 to the residual receipts account. The corrective response has already been put into place for this fiscal year.
Management agrees with the finding and will put processes and controls in place to verify timely deposits in the future. The required deposit of $4,477 was made in July 2025 to the residual receipts account. The corrective response has already been put into place for this fiscal year.
Management has agreed to work with the program administrator in order to get updated executed management agent certification.
Management has agreed to work with the program administrator in order to get updated executed management agent certification.
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