Corrective Action Plans

Finding 1159749 (2024-002)

Material Weakness 2024

Connecticut Harm Reduction Alliance, Inc.

CT

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Management will review retroactive calculations to ensure decimal point variances are identified prior to disbursement as in this case $35.104 vs $35.14

View Audit 370326

Finding 1159737 (2024-001)

Material Weakness 2024

End Domestic Abuse Wisconsin: the Wisconsin Coalition Against Domestic

WI

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs

Comments on findings and recommendations The organization agrees with the finding and the auditor’s recommendation. Actions taken or planned The organization reinstated the practice of preparing monthly financial statements to be reviewed by management and those charged with governance. Completion d...

Comments on findings and recommendations The organization agrees with the finding and the auditor’s recommendation. Actions taken or planned The organization reinstated the practice of preparing monthly financial statements to be reviewed by management and those charged with governance. Completion date September 30, 2024

View Audit 370321

Finding 1159736 (2024-002)

Material Weakness 2024

Okaloosa Aids Support and Informational Services INC Dba Oasis Florida

FL

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creati...

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.

View Audit 370319

Finding 1159731 (2024-002)

Material Weakness 2024

Seward Association for the Advancement of Marine Science

AK

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness...

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness and consistency of information. In addition, SAAMS will update its policies to clearly describe the review objectives and responsibilities of staff conducting payroll reviews. Training will be provided to relevant staff to ensure proper understanding and execution of the updated procedures. These measures will ensure payroll reviews are accurate, effective, and aligned with best practices. Completion Date: September 30, 2026 Responsible Person: Dr. Wei Ying Wong, CEO, SAAMS

View Audit 370314

Finding 1159706 (2024-004)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25

View Audit 370288

Finding 1159698 (2024-003)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Reporting Questioned Costs HUD Housing Programs § 200.303

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25

View Audit 370288

Finding 1159690 (2024-003)

Material Weakness 2024

The Family Conservancy, INC

KS

Allowable Costs / Cost Principles Questioned Costs § 200.403

Corrective Action Plan Identifying Number: 2024-003 Finding: The Agency did not properly allocate indirect costs during the fiscal period in which the corresponding direct costs were incurred, resulting in an indirect cost rate exceeding the de minimis rate for a portion of the 2024 fiscal period. C...

Corrective Action Plan Identifying Number: 2024-003 Finding: The Agency did not properly allocate indirect costs during the fiscal period in which the corresponding direct costs were incurred, resulting in an indirect cost rate exceeding the de minimis rate for a portion of the 2024 fiscal period. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with Uniform Guidance requirements for indirect costs, the following actions will be implemented: 1. Establish Written Indirect Cost Procedures – Develop and document procedures to ensure indirect costs are consistently calculated at the approved de minimis rate per the federal grant award on total direct costs during the performance period. 2. Implement Pre-Posting Review – Require a supervisory review of indirect cost calculations before charges are recorded to the general ledger and before grant reimbursements are submitted. We have implemented new procedures to ensure that indirect costs are included in each invoice for reimbursement. 3. Staff Training – Provide training for grants and finance staff on indirect cost requirements, the proper application of the de minimis rate, and reconciliation processes in accordance with 2 CFR 200.414(f). 4. Quarterly Reconciliations – Implement quarterly reconciliations of indirect costs applied to grants to confirm rates are applied correctly and consistently throughout the fiscal year. 5. Continuity Controls – Assign responsibility for indirect cost oversight to both a primary and a backup staff member to ensure consistency during periods of management turnover. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • New procedures: June 15, 2025 • Written procedures in place: December 31, 2025 • Staff training completed: January 31, 2026 • Supervisory review and reconciliations implemented: Beginning with January 2026 close

View Audit 370280 Questioned Costs: $1

Finding 1159688 (2024-001)

Material Weakness 2024

The Family Conservancy, INC

KS

Allowable Costs / Cost Principles Questioned Costs § 200.403

Corrective Action Plan Identifying Number: 2024-001 Finding: Expenditure was identified for one invoice with a 2023 service period that was improperly recorded, and reimbursed, as an expenditure in 2024, indicating improper expense recognition in accordance with US GAAP. Corrective Actions Taken or ...

Corrective Action Plan Identifying Number: 2024-001 Finding: Expenditure was identified for one invoice with a 2023 service period that was improperly recorded, and reimbursed, as an expenditure in 2024, indicating improper expense recognition in accordance with US GAAP. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with 2 CFR 200.403(e), the following actions will be implemented: 1. Establish Written Cutoff Procedures – Formal written procedures will be developed for reviewing service dates and supporting documentation prior to posting expenditures in the general ledger. These procedures will specifically address Uniform Guidance period-of-performance requirements. 2. Implement Supervisory Review – All expenditures charged to federal awards will undergo supervisory review at period-end. The review will confirm that expenses are recorded in the proper performance period before submission for reimbursement. Effective June 2025, the Vice President of Finance and the Controller performed a retrospective review of 2024 expenses to confirm that they were allocated to the correct reporting period. This supervisory review has continued into the current reporting period with no exceptions noted. 3. Staff Training – Grants and finance staff will receive focused training on Uniform Guidance cost principles, proper expenditure cutoff, and documentation standards to ensure consistent application. Staff training will include review of the finding and leadership will highlight the importance of verifying the correct reporting period for each entry. 4. Continuity Controls – To address turnover risk, responsibility for cutoff procedures will be assigned to both a primary and a backup staff member to provide coverage and reduce errors caused by staff changes. 5. Ongoing Monitoring – The VP of Finance will review quarterly grant compliance checklists and provide updates to senior leadership and the Finance Committee. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • Management supervisory review procedures: June 15, 2025 • Written cutoff procedures in place: December 31, 2025 • Staff training completed: January 31, 2026

View Audit 370280 Questioned Costs: $1

Finding 1159641 (2024-003)

Material Weakness 2024

Town of Dauphin Island

AL

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302

The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers ...

The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers using the new due-to due-from procedures. In addition, our staff is currently researching a variety of software programs in order to strengthen our in-house grant management procedures to maintain full compliance. The Town will also consider hiring additional personnel and/or soliciting the services of a professional grant manager to further assist with future grant opportunities, particularly those involving grant funds.

View Audit 370259

Finding 1159640 (2024-001)

Material Weakness 2024

Tmc Healthcare

AZ

Reporting Questioned Costs Subrecipient Monitoring § 200.328

Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Feder...

Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Federal Financial Report was not submitted timely and required performance reporting was not completed during the year. Questioned Costs - N/A Context - The Federal Financial Report for the reporting period end September 29, 2024 was due December 28, 2024, however, this was not submitted until February 25, 2025. Additionally, two (2) performance reports were due during the year, however, neither were completed. The first was for the period September 30, 2023 - March 31, 2024 and was due April 30, 2024, and the second was for the period April 1, 2024 - September 30, 2024 and was due October 30, 2024. Effect - The Company did not comply with federal reporting requirements. Cause - Management turnover caused uncertainty in assigned responsibilities, including this reporting requirement. Identification as a Repeat Finding - N/A Recommendation - The Company should review reporting requirements in grant award documents for all federal awards to ensure compliance. Client Planned Action: Benson Hospital agrees to the finding. The issue was identified in February of 2025 and the required reporting was completed and submitted. Going forward we have established a protocol by which reports for such Congressional Funding shall be submitted timely. Client Responsible Party: Mark Nellis, CFO; (520) 586-1873 Completion Date: February 22, 2025

View Audit 370254

Finding 1159585 (2024-002)

Material Weakness 2024

Westward Heights

WY

Questioned Costs Reporting Significant Deficiency § 200.327

Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate...

Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate time to prepare quarterly reports for submission to the USDA. Once the quarterly financials are finalized, the USDA report will be submitted no later than the last day of the month. This plan will also be added to the calendar with reminders set for the Administor to ensure timely review and submission.

View Audit 370235

Finding 1159584 (2024-001)

Material Weakness 2024

Franklin County Technical School District

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assess...

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assessment of existing procedures to identify gaps that led to noncompliance with grant regulations. • Ensure timely submission of grant applications. • Implement enhanced oversight and monitoring processes for all grant-related expenditures to ensure alignment with policy 2 CFR 200.1. • Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. • Ensure all documentation is easily accessible and systematically organized for audit purposes. • Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and only with written approval from the Federal awarding agency (as per 2 CFR 200.458). • Establish a process for obtaining and documenting written approval for pre-award costs. • Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. • Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. • Assign accountability for monitoring and reporting compliance to specific roles within the organization. The Business Manager, Elizabeth Bouchard, will be responsible for implementing this plan beginning with the Fiscal Year 2026 grant cycle. As of September 2025, non-compliance issues have been identified and addressed, documentation has been maintained to track award dates, and training has been provided to designated roles within the District. In addition, procedures to maintain detailed documentation of all award dates and expenditures to ensure a clear compliance record have been shared with all District Administrators utilizing grant funds.

View Audit 370226 Questioned Costs: $1

Finding 1159572 (2024-002)

Material Weakness 2024

Toole County

MT

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.

View Audit 370216

Finding 1159478 (2024-004)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Questioned Costs Material Weakness Reporting

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159472 (2024-002)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Questioned Costs Material Weakness Reporting

As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are prop...

As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159454 (2024-004)

Material Weakness 2024

School of Excellence in Education

TX

Questioned Costs Cash Management Reporting

No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation ...

No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation of approval for all monthly NSLP claims for reimbursement prior to submission. We will establish a formalized procedure to ensure that all monthly claims for reimbursement undergo documented management review and approval before submission. This procedure will clearly define the review process and designate responsible personnel for each step to maintain accountability. All reviewed and approved claims will be accompanied by signed documentation as evidence of compliance. All Food Service personnel involved in the reimbursement submission process will receive training on the new procedure to ensure understanding and adherence to the documentation requirements.

View Audit 370184

Finding 1159439 (2024-001)

Material Weakness 2024

Montefiore Health System, Inc.

NY

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.

View Audit 370177

Finding 1159428 (2024-002)

Material Weakness 2024

Mhub

IL

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.319 § 200.320

Condition: The Organization did not have controls to retain documentation that the procurement process was followed to ensure more than one vendor was reviewed for pricing before selecting the vendor chosen (as required under 2 CFR 320(a)(2)(i)). Planned Corrective Action: Management will implement ...

Condition: The Organization did not have controls to retain documentation that the procurement process was followed to ensure more than one vendor was reviewed for pricing before selecting the vendor chosen (as required under 2 CFR 320(a)(2)(i)). Planned Corrective Action: Management will implement controls to ensure proper support of the procurement process is retained. Contact person responsible for corrective action: Manas Mehandru, COO Anticipated Completion Date: December 31, 2025

View Audit 370163 Questioned Costs: $1

Finding 1159426 (2024-003)

Material Weakness 2024

Capital Region Minority Supplier Development Council

MD

Questioned Costs Matching / Level of Effort / Earmarking § 200.306

Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the ...

Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the support and documentation we provided we captured $191,000 (25% non-federal match) of in-kind to meet our obligation of $189,250 for grant award Year 1, 2023. And although we met our in-kind obligation, we experienced several delays which were recognized by our grantee, MBDA. The delay in funding the grant award took place from July 2023 to September 2023 and subsequently after funding was released an additional black-out period from September 2023 to October 2023 was experienced due to a system transition from BAS to GEMS/era Commons. Acknowledgement of these delays was addressed by an official during an MBDA All Equities call on October 18, 2023. During that call awardees were advised to continue focusing on our program activities and clients as the situation was being addressed. To account for the delays, we later submitted a budget revision request through the new system, eRA Commons on 12.09.2024 asking for a budget carryover of $337,825.00 which also outlines how the funds will be expended. Additionally, it is noted in your finding that the allowable in-kind contribution is being reduced given that budget categories were not met by line item. However, our interpretation of MBDA Capital Readiness NOFO (pg.14), we are directed to Section CFR200.306 [https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-D/section-200.306] which does not cap in-kind by line-item. Lastly, the MBDA organization has changed dramatically since the inception of the Capital Readiness grant in 2023, yet we have been in communication with an MBDA government official who acknowledges the delays during the time outlined above and ask that flexibility for this non-federal share requirement be re-considered. Supporting documentation has been sent to support the statements. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: We plan to continue to seek validation of our position from our grantor and grant management entity – 4th Quarter 2025.

View Audit 370152 Questioned Costs: $1

Finding 1159424 (2024-003)

Material Weakness 2024

Social & Environmental Entrepreneurs, Inc.

CA

Questioned Costs Allowable Costs / Cost Principles

Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to g...

Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to grants. Additionally, in the transactions tested for ALN 66.615, there was no sufficient documentation to support the total fringe benefit amounts charged to the grants. Repeat Finding: Yes, similar deficiencies noted in 2023‐003. Views of Responsible Officials: There was a finding that was noted related to the tracking of personnel costs to the federally funded contract. SEE Accounting and Administration, which includes HR, has established and implemented uniform timekeeping procedures requiring all employees, both exempt and non-exempt, whose salaries are charged to federal contracts to submit accurate and complete timecards that reflect the actual hours worked. These formal procedures are monitored, reviewed, and reconciled on a monthly basis. Official Responsible for Ensuring CAP: Jennifer Hoffman, CEO; Anna Zaricki, CFO; Trevis Bird, COO; Monique Gutierrez, Sr-HRD; Arthur Doi, Controller; and Justin Yamashiro, Audit Manager are responsible for ensuring corrective action is implemented. Planned Completion Date for CAP: December 31, 2026

View Audit 370147 Questioned Costs: $1

Finding 1159421 (2024-001)

Material Weakness 2024

Brooklyn Plaza Medical Center, Inc.

NY

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the Decemb...

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO

View Audit 370146

Finding 1159418 (2024-001)

Material Weakness 2024

Fort Lee Housing Authority

NJ

HUD Housing Programs Questioned Costs Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Action: The Authority contracted with an Agency which performed all rent reasonableness calculations, however, a copy of the calculations could not be located at the time of audit. The Authority has implemented a process whereby all completed ren...

Views of Responsible Officials and Planned Corrective Action: The Authority contracted with an Agency which performed all rent reasonableness calculations, however, a copy of the calculations could not be located at the time of audit. The Authority has implemented a process whereby all completed rent reasonableness calculations will be stored in the related tenant file. Terrence Corriston, Executive Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 370143

Finding 1159417 (2024-004)

Material Weakness 2024

Supports to Encourage Low Income Families INC

OH

Questioned Costs Reporting Internal Control / Segregation of Duties

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.

View Audit 370141

Finding 1159416 (2024-002)

Material Weakness 2024

Gowest Foundation

WA

Eligibility Questioned Costs Matching / Level of Effort / Earmarking § 200.303 § 200.518

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

View Audit 370140 Questioned Costs: $1

Finding 1159415 (2024-001)

Material Weakness 2024

Gowest Foundation

WA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

View Audit 370140 Questioned Costs: $1

Corrective Action Plans

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