Corrective Action Plans

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5. Conduct periodic internal reviews to ensure no reportable credit balances exist, even if formal reports are no longer required.
5. Conduct periodic internal reviews to ensure no reportable credit balances exist, even if formal reports are no longer required.
Corrective Actions Taken:
Corrective Actions Taken:
1. The overdue Medicare Cost Report for FYE 2024 was filed and accepted by CMS on September 22, 2025.
1. The overdue Medicare Cost Report for FYE 2024 was filed and accepted by CMS on September 22, 2025.
2. A centralized compliance calendar was developed and is maintained by the CEO to track all federal, state, and grant-related deadlines.
2. A centralized compliance calendar was developed and is maintained by the CEO to track all federal, state, and grant-related deadlines.
3. Oversight of the Medicare Cost Report was formally assigned to the CEO and incorporated into SCMRC’s internal and board planning processes.
3. Oversight of the Medicare Cost Report was formally assigned to the CEO and incorporated into SCMRC’s internal and board planning processes.
4. Medicare Cost Report deadlines are reviewed monthly during Finance Committee meetings to ensure accountability.
4. Medicare Cost Report deadlines are reviewed monthly during Finance Committee meetings to ensure accountability.
5. SCMRC leadership received training in 2024 on CMS reporting requirements and nonprofit compliance timelines.
5. SCMRC leadership received training in 2024 on CMS reporting requirements and nonprofit compliance timelines.
6. SCMRC engaged Allen Bryant, CPA, to support timely Medicare Cost Report preparation and submission going forward.
6. SCMRC engaged Allen Bryant, CPA, to support timely Medicare Cost Report preparation and submission going forward.
7. SCMRC’s updated compliance tracking system was reviewed during the 2025 HRSA Verification Site Visit, contributing to the clearance of Chapter 18 conditions.
7. SCMRC’s updated compliance tracking system was reviewed during the 2025 HRSA Verification Site Visit, contributing to the clearance of Chapter 18 conditions.
Corrective Action Plan:
Corrective Action Plan:
1. Maintain the centralized compliance calendar with documented Medicare Cost Report deadlines, reviewed monthly.
1. Maintain the centralized compliance calendar with documented Medicare Cost Report deadlines, reviewed monthly.
2. Ensure continued CEO oversight of Medicare Cost Report submissions, with responsibilities reaffirmed annually during internal planning.
2. Ensure continued CEO oversight of Medicare Cost Report submissions, with responsibilities reaffirmed annually during internal planning.
3. Continue monthly Finance Committee updates on Cost Report timelines and submission status.
3. Continue monthly Finance Committee updates on Cost Report timelines and submission status.
4. Provide refresher training as needed to maintain awareness of CMS and HRSA reporting requirements.
4. Provide refresher training as needed to maintain awareness of CMS and HRSA reporting requirements.
5. Retain Allen Bryant, CPA, for annual preparation and submission of the Medicare Cost Report in accordance with CMS deadlines.
5. Retain Allen Bryant, CPA, for annual preparation and submission of the Medicare Cost Report in accordance with CMS deadlines.
Corrective Actions Taken:
Corrective Actions Taken:
1. Implemented a 15-month rolling cash flow forecast in Q4 2024, updated weekly by the CEO and Controller in partnership with the contract accountant.
1. Implemented a 15-month rolling cash flow forecast in Q4 2024, updated weekly by the CEO and Controller in partnership with the contract accountant.
2. Finance staff monitor cash balances and disbursements at least twice per week to anticipate timing issues and support grant drawdown coordination.
2. Finance staff monitor cash balances and disbursements at least twice per week to anticipate timing issues and support grant drawdown coordination.
3. Established internal minimum balance thresholds and enabled low balance alerts to prevent overdrafts.
3. Established internal minimum balance thresholds and enabled low balance alerts to prevent overdrafts.
4. Consolidated underutilized accounts in 2025 and formalized contingency planning with SCMRC’s banking institution.
4. Consolidated underutilized accounts in 2025 and formalized contingency planning with SCMRC’s banking institution.
5. Conducted nonprofit cash flow management training for the CEO, Controller, and Board in Q2 FY25.
5. Conducted nonprofit cash flow management training for the CEO, Controller, and Board in Q2 FY25.
6. Included cash flow forecasting and liquidity discussions in monthly Finance Committee updates.
6. Included cash flow forecasting and liquidity discussions in monthly Finance Committee updates.
7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.
7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.
Corrective Action Plan:
Corrective Action Plan:
1. Continue weekly updates of the 12-month rolling cash flow forecast.
1. Continue weekly updates of the 12-month rolling cash flow forecast.
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