Corrective Action Plans

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CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Spokane January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 2...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Spokane January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2024-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of City contact person: Skyler Brown, Grants and Contracts Financial Manager W 808 Spokane Falls Blvd Spokane, WA 99201 (509) 625-6294 Corrective action the auditee plans to take in response to the finding: The City currently has a contracting process to verify and document its contractors, consultants and vendors are neither debarred nor suspended. This process adds required certification language to all City agreements to document compliance. While this purchase was reviewed and the compliant status of the providers were verified through the existing cooperative agreement, the City’s process did not capture the needed requirement to verify at the lower tier. This was identified in the prior audit, and due to the timing of this issue and the prior audit finding, the corrections put in place to catch these kinds of purchases going forward had not been put in place yet, and the debarment search on this purchase occurred after the purchase had been made. The City has put into place a requirement that all subawards, purchase agreements and contracts involving federal funds over $25,000 include the required certification even if the contract is derived from “piggy backing” and includes debarment language. Every Contract that receives grant funding goes through the Grants office during the contracting approval process, and this debarment upload is something Grants office is now looking for before approving a contract to move further along the approval process. Anticipated date to complete the corrective action: Currently Active
August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #5 – Sovereign Equity Fund – Fisc...
August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #5 – Sovereign Equity Fund – Fiscal Year End 12/31/2024 To Whom It May Concern: FFATA Reporting - Organization failed to report first-tier subawards in the FSRS system as required under the Federal Funding Accountability and Transparency Act. Corrective Actions: • Designate a responsible party to oversee FFATA compliance. • Update award tracking system to recognize and implement procedures for all first-tier subawards ≥$30,000 for FFATA reporting. • Incorporate FFATA reporting deadlines into grants calendar (due by the end of the month following the award date). • Provide FFATA compliance training and ensure timely access to FSRS.gov. Responsible Party: Executive Director Target Completion Date: Within 14 days; calendar tracking system in use for next subaward Sincerely, Courtney Chavis Executive Director
August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #4 – Sovereign Equity Fund – Fisc...
August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #4 – Sovereign Equity Fund – Fiscal Year End 12/31/2024 To Whom It May Concern: Subrecipient Monitoring - Subrecipient agreements lacked required federal clauses and were not monitored according to risk assessments. Corrective Actions: • Develop a subrecipient monitoring policy aligned with 2 CFR §200.331-333. • Standardize agreement templates to include all required clauses for federal award subrecipient agreements (e.g., audit requirements, FFATA, termination provisions). • Implement a subrecipient risk assessment tool to determine monitoring frequency and risk level identification. • Assign staff for annual subrecipient desk reviews or site visits based on risk levels. Responsible Party: Executive Director / Legal & Compliance Team Target Completion Date: Risk assessment and financial monitoring tool in use and agreement templates updated within 45 days. Sincerely, Courtney Chavis Executive Director
August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #3 – Sovereign Equity Fund – Fisc...
August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #3 – Sovereign Equity Fund – Fiscal Year End 12/31/2024 To Whom It May Concern: Funds were drawn down in advance under a reimbursement-based award, potentially violating federal cash management standards (2 CFR §200.305). As referenced and in relation to Finding #2 - Grant funds were drawn in excess of current expenditure needs, which resulted in the Organization being required to return the excess funds to the federal government. 2024-002 – Cash Management, 2 CFR 200.305 (Payment). Corrective Actions: • The Organization has returned the excess funds to the federal government.. • Revise internal procedures to include verification of expenditures for eligible and allowable expenses before initiating a draw request. • Develop a drawdown checklist and require supporting documentation for incurred costs, retain supporting documentation for all drawdowns. • Require Executive Director approval prior to all federal drawdowns. • Conduct training on federal reimbursement protocols for program and finance staff. Responsible Party: Grants Manager / Executive Director Target Completion Date: Policy update within 2 weeks; checklist rollout within 30 days Sincerely, Courtney Chavis Executive Director
View Audit 367244 Questioned Costs: $1
Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Th...
Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2024 Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the City adopt a procurement policy that includes procedures over suspension and debarment. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The City will prepare a policy and have it adopted by the City Council. Name of the Contact Person Responsible for Corrective Action Plan: Emily Burns, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2025.
Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Ag...
Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2024 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the HRA implement controls over all areas of the federal program so that controls are in place and working. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The HRA will assess the controls over the federal program and make changes as deemed necessary. Name of the Contact Person Responsible for Corrective Action Plan: Emily Burns, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2025.
Corrective Actions Taken:
Corrective Actions Taken:
1. A revised SFDP policy aligned with HRSA compliance standards was approved by the Board in early 2024 and implemented across all sites.
1. A revised SFDP policy aligned with HRSA compliance standards was approved by the Board in early 2024 and implemented across all sites.
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.
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