Corrective Action Plans

Finding 1155461 (2024-002)

Material Weakness 2024

Aid Upstate

SC

Cash Management Significant Deficiency

Contact Person: Tracy Carr, Rajee Rao Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: A schedule has been developed which has enabled the submission of the monthly grant reim...

Contact Person: Tracy Carr, Rajee Rao Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: A schedule has been developed which has enabled the submission of the monthly grant reimbursement reports by the due date. It has required a group effort by the entire staff and the individual members of the finance team in the responsibilities to meet the deadline. The continued use of this schedule has proven to keep the process on track and allow the organization to adhere to the grant deadlines. Completion Date: Beginning June 1, 2024 and thereafter.

View Audit 367743

Finding 1155384 (2024-001)

Material Weakness 2024

Cheyenne Health and Wellness Center Doing Business As Healthworks

WY

Reporting Allowable Costs / Cost Principles Material Weakness

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. ...

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. For the 2025 UDS report accrued PTO for employees will not be included employee expenses. Contact person responsible for corrective action: Margaret Cox CFO mcox@wyhealthworks.org

View Audit 367639

Finding 1155370 (2024-004)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties Significant Deficiency

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1...

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1, 2025

View Audit 367616

Finding 1155369 (2024-003)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties HUD Housing Programs

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Ac...

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: September 18, 2025

View Audit 367616

Finding 1155367 (2024-001)

Material Weakness 2024

Suffolk County, New York

NY

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant...

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant eligibility, nor did it ensure that non-long-term care program participants were properly classified. Sixty participants were selected for testing and the following exceptions were noted: • For five of sixty participants selected for testing, the County was unable to provide documentation that a program supervisor had approved the application. • For one of sixty participants selected for testing, the County was unable to provide a signed participant application. • For one of sixty participants selected for testing, upon reapplication and further documentation, a long-term care case was determined to be non-long-term care, but the County did not make this change and the participant was misclassified. Questioned Costs Undetermined. Recommendation The County should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility. It should also enhance procedures and internal controls to ensure participants are correctly classified as long-term care versus non-long-term care. Corrective Action Plan The Medicaid Division will continue to emphasize the need for signatures at both levels of eligibility Examiner level and Quality Control Examiner II or higher level. This will be stressed at all appropriate training for not only new staff but current staff as well. As far as the “misclassified” the Consumer left nursing home during a period when documentation requirements were waived, due to the Public Health Emergency (COVID-19); The coverage was correct, but coding indicated the need for Long Term Care. This code does not allow or authorize any services on its own, and as such, no inappropriate services were authorized. Even though this has little impact the Division will continue to stress to staff and supervisors the need to properly code cases. NYS DOH is in the process of transitioning away from LDSS 3209 forms and automating the process; we will continue to work with our state partners to assist in this transition when it becomes available to us. This transition should mitigate these type of situations. Action Date September 5, 2025 Final Implementation Date December 31, 2025 Name And Phone No. Of Person Responsible For Implementation James Sluder – 631-854-5830

View Audit 367602

Finding 1155354 (2024-002)

Material Weakness 2024

Goodwill Industries of Michiana, Inc.

IN

Cash Management Significant Deficiency Internal Control / Segregation of Duties

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to...

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to submit reimbursements. Recommendation: The Organization should perform and maintain monthly reconciliations of the payroll software, general ledger, and draw detail that all agree. Action Taken: The Organization was billing the grantor for payroll fees, the additional fees for each employee or contract that participated in the grant. Originally, the funds were coded to payroll (compensation) expenses, which generated a discrepancy between the Payroll Register and the General Ledger. The unemployment expense was also coded to benefits, which created a variance between the payroll register (generated from payroll software) and the general ledger. Going forward, the trail balance and general ledger will be reconciled to the draw request. Additionally, the team has been trained in how to properly code these expenses. Contact Person: Shire Kuch Effective Date: 25 September 2025.

View Audit 367596

Finding 1155330 (2024-005)

Material Weakness 2024

City of Muskegon Heights

MI

Allowable Costs / Cost Principles Cash Management Reporting

2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not ...

2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not report any current period expenditures. Rather, the cumulative expenditures for the year were included in the fourth quarter Project and Expenditure report. In addition, the Project and Expenditure reports for the third and fourth quarters of 2024 were not filed within the required timeframe. As a result of this condition, the City did not comply completely with the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds grant. Auditor Recommendation. We recommend that the City review the reporting requirements for each grant and complete all required reporting as required under the terms of the grant agreement. Corrective Action. City staff has accessed these reports and attempted to submit all required reports. Ongoing reports have been submitted on time. Assistance will be sought with federal agencies as necessary. Responsible Person. Finance Director Anticipated Completion Date. December 31, 2025

View Audit 367568

Finding 1155277 (2024-002)

Material Weakness 2024

Sibley County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A ...

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A at least 2 times per month to identify outstanding verifications for MA cases in METS. This will identify specific cases missing SSN verifications. Anticipated Completion Date: The MNCM 220A reported is generated quarterly. The anticipated completion date is October 6th for the next quarterly report.

View Audit 367509

Finding 1155276 (2024-001)

Material Weakness 2024

Health Education Learning Project

TX

Allowable Costs / Cost Principles Reporting Significant Deficiency

This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immed...

This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immediately to ensure the deficiency no longer occurs. Specifically, an active confirmation of billing amounts matching the general ledger from the CPA to the CEO has been added to our internal controls. Previously, the CPA only contacted the CEO if there was a need for correction. As stated in the audit report, this error occurred during the transition time between our contracted CPA and the new CFO beginning. Neither the CPA nor the CFO informed the CEO of the discrepancy between the billing and general ledger amounts, and therefore no correction was made or even looked for. This finding identified a flaw in our existing internal controls if the CPA does not complete the final validation process. Below are the internal control procedures for grant billing that were in place at the time of the error with the new addition in red: • All time sheets are forwarded to the CPA. • The CPA, or their designee, develops a payroll report utilizing the timesheets to allocate payroll by work function. • The payroll report is forwarded to the CEO for approval and billing purposes. • The detailed monthly billing is sent to the CPA for verification that the billing matches the general ledger. • The CPA will send an email to the CEO either confirming the amounts billed match the general ledger or identifying the need for a billing/general ledger correction. • Any discrepancies between billing and the general ledger are corrected via a corrected billing being submitted or a general ledger journal entry being made to reallocate costs. The organization is confident the above augmented internal control procedures will provide the necessary oversight and quality control measures needed to ensure the identified deficiency from recurring. The CEO is responsible for monitoring and ensuring compliance with the revised internal control measures.

View Audit 367506

Finding 1155259 (2024-003)

Material Weakness 2024

Boys & Girls Club of Brazoria County

TX

Reporting Significant Deficiency

Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Recommendation: Establish policies an...

Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Recommendation: Establish policies and procedures to record all federal expenditures in the general ledger system by class code in order to generate a report of expenditures by grant. Planned corrective action: Government funded transactions will be recorded in our general ledger in a manner which facilitates reporting by federal award. Management will review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.

View Audit 367470

Finding 1155257 (2024-004)

Material Weakness 2024

Boys & Girls Club of Brazoria County

TX

Cash Management Allowable Costs / Cost Principles Significant Deficiency

Finding #2024-004 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found one instance of reimbursement by the grantor approximately five months before payment was made to the vendor. Recommendation: Strengthen controls to ensure that invo...

Finding #2024-004 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found one instance of reimbursement by the grantor approximately five months before payment was made to the vendor. Recommendation: Strengthen controls to ensure that invoices are paid in a timely manner to ensure federal reimbursements are not being held for an excess period of time. Planned corrective action: As part of our enhanced review of government transactions, we will be mindful that federal reimbursement requests should only include expenses that have been disbursed or have been accrued with expectation of disbursement in a timely manner. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.

View Audit 367470

Finding 1155255 (2024-002)

Material Weakness 2024

Boys & Girls Club of Brazoria County

TX

Cash Management Reporting Significant Deficiency

Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions a...

Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions are reviewed, reconciled, and include applicable accruals. Management will review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.

View Audit 367470

Finding 1155204 (2024-003)

Material Weakness 2024

Wilkes-Barre/scranton International Airport

PA

Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management

Finding 2024-003 Condition: As part of our audit of the Federal Aviation Administration Program, it was noted that the Airport did not adopt written policies/procedures surrounding certain areas to comply with the requirements of the Uniform Guidance Corrective Action Plan: Corrective Action Planned...

Finding 2024-003 Condition: As part of our audit of the Federal Aviation Administration Program, it was noted that the Airport did not adopt written policies/procedures surrounding certain areas to comply with the requirements of the Uniform Guidance Corrective Action Plan: Corrective Action Planned: Airport Finance department has adopted written policies and procedures to satisfy Uniform Guidance Name(s) of Contact Person(s) Responsible for Corrective Action: Director of Finance Anticipated Completion Date: August 1, 2025

View Audit 367446

Finding 1155070 (2024-003)

Material Weakness 2024

City of Gary

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Respon...

FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Response to Finding: Segregation of Duties and Oversight of Required FFATA Reporting To address the finding related to segregation of duties and the lack of an established oversight or review process for required reports submitted under the Federal Funding Accountability and Transparency Act (FFATA), the Department of Community Development will implement a formalized review process. This process will include the use of a signature form to document the roles of the: • Preparer – responsible for compiling the report, • Reviewer – responsible for independently verifying the report’s accuracy, and • Submitter – responsible for final submission of the verified report. All parties will be required to sign the form upon completion of their respective responsibilities, ensuring accountability, verification of data accuracy, and compliance with FFATA reporting requirements. Anticipated Completion Date: February 2026

View Audit 367388

Finding 1155031 (2024-001)

Material Weakness 2024

Watts Healthcare Corporation

CA

Questioned Costs Subrecipient Monitoring Cash Management

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients a...

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025

View Audit 367364 Questioned Costs: $1

Finding 1154978 (2024-003)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.

View Audit 367318

Finding 1154977 (2024-002)

Material Weakness 2024

Elm Hill Water District

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.

View Audit 367318

Finding 1154976 (2024-001)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.

View Audit 367318

Finding 1154955 (2024-003)

Material Weakness 2024

Waushara County

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.

View Audit 367288

Finding 1154951 (2024-005)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

HUD Housing Programs Period of Performance Significant Deficiency

Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are no...

Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are not considered obligated until the PHA has budgeted and drawn down the funds. To meet this requirement, the funds must be budgeted in line BLI 1406 (Operations) and the PHA must submit the voucher request in LOCCS. (24 CFR Section 905.314(I)). Statement of Concurrence or NonConcurrence: The Authority had obligated capital funds related to operations (BLI 1406) for Capital Fund years 2020 and 2022 prior to the voucher request date for these draws. The Authority had six open capital fund grants during fiscal year 2024 (Capital Fund years 2019-2024). The Authority obligated the BLI 1406 funding for Capital Fund 2020 in March 2024 and Capital Fund 2022 in May 2024. The Authority submitted the voucher requests in February 2025. Corrective Action: Funds in 1406 will be drawn down directly after obligation. Name of Contact Person: Cheryl Thibeault Projected Completion Date: 09/30/2025

View Audit 367267

Finding 1154943 (2024-001)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Reporting Subrecipient Monitoring HUD Housing Programs § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: Th...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). The review and approval occurred after the FFATA subaward was submitted to the FSRS. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has created a policy regarding the FFATA reporting process. In this process the Electronic Handbook (EHB) is reviewed weekly to ensure that if new awarded funding is released, BCHN is alerted to the need to complete the FFATA report. BCHN has created a spreadsheet to track all the awarded funding and due dates for FFATA reports. Every month, at the board meeting, the spreadsheet is presented to the board with any new awarded funding and when the FFATA report is completed. BCHN has begun a process where the FFATA report is put together by the Finance Manager and reviewed and signed off by the CFO before submitting the report. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154942 (2024-004)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Allowable Costs / Cost Principles HUD Housing Programs Period of Performance § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencin...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154833 (2024-008)

Material Weakness 2024

El Programa Hispano Catolico

OR

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...

The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. EPHC has been behind on financial statements and previously were not able to submit the semi-annual financial statements. As of June 30, 2025, the first semi-annual financial statements was submitted.

View Audit 367181

Finding 1154832 (2024-007)

Material Weakness 2024

El Programa Hispano Catolico

OR

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...

The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. To ensure timely submission of the performance reports, EPHC will use Sales Force software to track all due dates. This system will send reminders and will record submission dates. To ensure review of all performance reports, procedures will be put in place outlining roles and responsibilities of report preparation by managers and review by Program Directors.

View Audit 367181

Finding 1154831 (2024-006)

Material Weakness 2024

El Programa Hispano Catolico

OR

Special Tests & Provisions Eligibility Significant Deficiency

EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper ...

EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper documentation.

View Audit 367181

Corrective Action Plans

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