Corrective Action Plans

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2. Eligibility documentation procedures were updated: staff now document income and family size at intake, visually mark the applicable discount level on the SFDP form, and enter discount data into the patient’s EHR.
2. Eligibility documentation procedures were updated: staff now document income and family size at intake, visually mark the applicable discount level on the SFDP form, and enter discount data into the patient’s EHR.
3. Clinic signage and intake materials were revised to ensure all patients are informed of the SFDP at the point of service.
3. Clinic signage and intake materials were revised to ensure all patients are informed of the SFDP at the point of service.
4. Intake and billing staff received training on SFDP eligibility, documentation, and communication protocols in 2024, with annual refreshers planned.
4. Intake and billing staff received training on SFDP eligibility, documentation, and communication protocols in 2024, with annual refreshers planned.
5. In February 2025, SCMRC transitioned to a new revenue cycle management (RCM) vendor, improving accuracy in SFDP patient setup and billing workflows.
5. In February 2025, SCMRC transitioned to a new revenue cycle management (RCM) vendor, improving accuracy in SFDP patient setup and billing workflows.
6. Monthly CQI chart audits now include a review of SFDP documentation and eligibility determinations to monitor compliance.
6. Monthly CQI chart audits now include a review of SFDP documentation and eligibility determinations to monitor compliance.
Corrective Action Plan:
Corrective Action Plan:
1. Maintain annual training on SFDP policies and documentation for all intake and billing staff.
1. Maintain annual training on SFDP policies and documentation for all intake and billing staff.
2. Continue including SFDP compliance checks in monthly CQI chart audits.
2. Continue including SFDP compliance checks in monthly CQI chart audits.
3. Conduct annual reviews of SFDP utilization trends, fee schedule accuracy, and patient communication practices.
3. Conduct annual reviews of SFDP utilization trends, fee schedule accuracy, and patient communication practices.
4. Include SFDP updates in Compliance Committee reports, with findings presented annually to the Board.
4. Include SFDP updates in Compliance Committee reports, with findings presented annually to the Board.
5. Continue coordination between front desk, billing, and RCM teams to ensure proper EHR setup for all SFDP patients.
5. Continue coordination between front desk, billing, and RCM teams to ensure proper EHR setup for all SFDP patients.
Corrective Actions Taken:
Corrective Actions Taken:
1. A Board-approved Budgeting Policy was implemented and most recently revised in June 2025.
1. A Board-approved Budgeting Policy was implemented and most recently revised in June 2025.
2. Separate budgets are now developed and maintained for federal, non-federal, and total project funds. Each federal award is budgeted and monitored independently.
2. Separate budgets are now developed and maintained for federal, non-federal, and total project funds. Each federal award is budgeted and monitored independently.
3. Budget-to-actual activity is reviewed monthly using standardized variance reporting tools.
3. Budget-to-actual activity is reviewed monthly using standardized variance reporting tools.
4. The CEO is responsible for ensuring that all expenditures align with the HRSA-approved total project budget.
4. The CEO is responsible for ensuring that all expenditures align with the HRSA-approved total project budget.
5. Budget revisions are evaluated under 45 CFR § 75.308, and HRSA prior approval is requested when required.
5. Budget revisions are evaluated under 45 CFR § 75.308, and HRSA prior approval is requested when required.
6. All budgets and budget modifications are approved by the Board of Directors and reflected in monthly financial management reports.
6. All budgets and budget modifications are approved by the Board of Directors and reflected in monthly financial management reports.
Corrective Action Plan:
Corrective Action Plan:
1. The Controller, outside account and CEO conduct monthly budget-to-actual reviews for all federal awards, using variance analysis tools.
1. The Controller, outside account and CEO conduct monthly budget-to-actual reviews for all federal awards, using variance analysis tools.
2. Variance reports are submitted to the CEO and reviewed with the Finance Committee on a monthly basis.
2. Variance reports are submitted to the CEO and reviewed with the Finance Committee on a monthly basis.
3. HRSA budget categories were added to the general ledger in 2024 to enable accurate expenditure tracking by category.
3. HRSA budget categories were added to the general ledger in 2024 to enable accurate expenditure tracking by category.
4. Training on budget monitoring and federal requirements was conducted in June 2024 and will be repeated annually.
4. Training on budget monitoring and federal requirements was conducted in June 2024 and will be repeated annually.
5. Budget compliance is reviewed quarterly as part of SCMRC’s internal financial monitoring processes.
5. Budget compliance is reviewed quarterly as part of SCMRC’s internal financial monitoring processes.
Corrective Actions Taken:
Corrective Actions Taken:
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