Audit 413181

Finding 2025-002 - Procurement and Suspension and Debarment - Significant Deficiency Name of Federal Agency: U.S. Department of Health and Human Services. Federal Program Names: Health Center Program and Grants for New and Expanded Services Under the Health Center Program. Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Numbers and Years: Health Center Program Cluster: H80CS00626‐2023, H8KCS49691-2023, H8KCS49691-2024, H8ICS53459-2024 Criteria In accordance with 2 CFR 200.214, nonfederal entities are subject to the nonprocurement debarment and suspension regulations. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Condition During our audit, we noted that BCHN did not perform a check at the System for Award Management Exclusions (sam.gov) to verify whether a vendor had been suspended or debarred before being hired. Cause As a result of personnel changes, the check was not timely performed. Effect or Potential Effect The condition could result in vendors who are suspended or debarred receiving federal funds. Questioned Costs None. Context One exception from a statistically valid sample of eight. Identification as a Repeat Finding Yes (see prior year finding number 2024-002) Recommendation We recommend Human Resources (HR) personnel/management perform a check at sam.gov prior to the hire of an vendor to ensure the vendor was not suspended or debarred and retain evidence of that verification, including the date it was performed. Views of Responsible Officials The vendor that was selected during the audit was hired in March of 2025. Since that time, BCHN has implemented a process by which all new employees and new vendors are added to the Exclusion Screening LLC database. We engaged Exclusion screening LLC because they check for exclusion and debarment on the OIG, SAM and state exclusion lists monthly, once entered in the system. This process ensures that all new vendors or employees are screened upon hire and are then automatically screened going forward. Bronx Community Health Network, Inc. and Affiliate Schedule of Findings and Questioned Costs Year Ended December 31, 2025 38

Finding 2025-003 - Reporting - Significant Deficiency Name of Federal Agency: U.S. Department of Health and Human Services. Federal Program Names: Health Center Program and Grants for New and Expanded Services Under the Health Center Program. Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Numbers and Years: Health Center Program Cluster: H80CS00626‐2023, H8KCS49691-2023, H8KCS49691-2024, H8ICS53459-2024 Criteria In accordance with 2 CFR Section 200.303, Internal Controls, the non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition During our audit, we noted that there was no evidence of the review and approval of the Uniform Data System (UDS) before its submission. Cause There is no formal policy in place requiring the CEO (or designee) to review and approve the UDS report before submission. Effect or Potential Effect The condition could result in key data elements being inaccurately reported and/or not supported by the source documentation. Questioned Costs None. Context One exception from a sample of one. Identification as a Repeat Finding No Recommendation We recommend that the UDS report be reviewed and approved by the CEO or designee before submission and evidence of approval be maintained. Views of Responsible Officials Management has implemented a formal UDS review and approval process requiring management review and documented approval by the designated responsible official prior to submission. In this process, the CFO will email the draft UDS report to the CEO for review. Once the UDS is reviewed, the CEO will email the CFO approving the UDS report. Then the CFO will submit the report. Evidence of the review and approval will be maintained and retained with the final UDS submission documentation to ensure accuracy, completeness, and compliance with reporting requirements.