Corrective Action Plans

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County did not have effective internal controls in place to ensure that P&E reports submitted were accurate. This allowed errors on P&E reports to remain undetected and uncorrected. It was recommended that policies and procedures be put in place to ensure that all reports were complete and accurate. Contact Person Responsible for Corrective Action: Pia O’Connor Contact Phone Number and Email Address: 812-379-1510 and pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County implemented an additional procedure to ensure we have complete and accurate information for the P & E report. Beginning with the 3rd Quarter P&E report, the County had added a person to assist with these reports by creating the reports through our financial software and reviewing the figures and information before giving the reports to the Auditor. The County Auditor prepared the P & E reports and then the Commissioner’s reviewed before the Auditor submitted the report to the Treasury. Due to the financial software (Software Solutions), there were reporting issues between quarters. The Bartholomew County Auditor’s Office continuously strives to improve upon our process and during 2024, changed financial software to LOW Financial to help with reporting and will implement an additional check and balance prior to the Treasury. Anticipated Completion Date: December 31, 2024

FINDING 2023-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County had not implemented procurement policy or procedures for procuring goods and services paid with Federal funds. The County did not have policies or procedures in place to verify that the entities which they entered into covered transactions were not suspended, debarred, or otherwise excluded. Four out of seven covered transactions were selected for testing, and none of the contractors’ suspension or debarment statuses were checked prior to payment. Contact Person Responsible for Corrective Action: Pia O’Connor Contact Phone Number and Email Address: 812-379-1510 and pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will continue to work with the Commissioner’s Office and other county departments to improve upon the process of administering the COVID-19 Coronavirus State and Local Fiscal Recovery Fund. The County implemented a Procurement, Suspension and Debarment Policy; however it did not specifically reference federal funds. The County will amend the current policy to include the necessary verbiage and information related to the federal funds. By establishing this system of Internal Controls and developing the proper policies and procedures, this should help ensure contractors and sub recipients, as appropriate are not suspended, debarred or otherwise excluded prior to entering any contacts or sub awards. Anticipated Completion Date: December 31, 2024

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and submitted each report without a review or oversight process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-003, the Chief of Staff to the Board of Commissioners will have the Controller to the Board of Commissioners review the P&E Reports and the Recovery Plan Performance Report prior to being electronically submitted to the Department of Treasury via its State and Local Fiscal Recovery Funds portal. If errors are discovered by the Controller, the Chief of Staff will correct the electronic entry prior to submission. Anticipated Completion Date: This CAP will be completed by October 31, 2024, the deadline for submitting the third quarter 2024 P&E Report.

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purpose of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. The Health Issues and Challenges grant is a reimbursable grant, whereby the County received reimbursement on a percase basis at a stated rate for Case Management and Environmental Investigation activities performed. The Department of Health received federal receipts related to the grant in the amount of $130,479 during 2023. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. Receipts of the program were adequately identified through the use of an account number within the County Health Fund (285) in the Allen County's ledger (ledger) which was unique to the Health Issues and Challenges grant receipts. However, the ledger did not adequately identify the expenditures of the grant program within the County Health Fund. Through inquiry with the Department of Health employees and review of unitprepared support of grant expenditures, we determined expenditures were made with grant funds during the audit period, however, we were unable to distinguish between the expenditures of the Health Issues and Challenges grant and all other activities of the Department of Health in the County Health Fund. Due to the lack of separate identification of expenditures in the financial records, we were not able to establish a population from which to audit the Health Issues and Challenges grant for compliance with the following compliance requirements of the program: 􀁸 Activities Allowed or Unallowed 􀁸 Allowable Costs/Cost Principles 􀁸 Period of Performance 􀁸 Procurement and Suspension and Debarment As such, the full award amount of $130,479, as reported on the Schedule of Expenditures of Federal Awards, was determined to be questioned costs. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Recommendation: We recommend that management of the Health Department establish a system of internal controls to ensure that grant award funds are adequately accounted for and tracked in such a manner as to determine the activity, receipts and disbursement, associated with the grant. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: When we were informed of the outcomes of the SBOA audit and the subsequent needs for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP. We feel this finding/issue could be easily remedied by following our normal procedure for grants, whereby we develop a new fund, craft a Fund Ordinance for approval by the Allen County Commissioners to establish said new fund, and then subsequently track all expenditures and reimbursements in the separate fund vs. utilizing a line item for deposits in the main Health Fund as was done with this grant (which lacked the ability to denote exact salary expenditures and such next to each payment as it was all done within the larger fund for all staff and expenses. We were not aware of this need. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a separate fund will be created through development and approval of a local fund ordinance. All expenditures allowed by said grant and all reimbursements received by the grant funder will be tracked solely and only within the separate grant fund that is tied to the signed contract from the funder. If there are staff payments for salaries or benefits being reimbursed by a grant, we will ensure that: (1) the hours/minutes per staff member per pay period for all work associated with these grant duties are tracked appropriately so as to ensure we are invoicing the grant funder for the exact and accurate work hours (regardless of whether or not the grant contract specifies this be tracked or reimbursed per minute/hour, as most do not require this); and (2) these amounts will be noted alongside the expenditures in the grant fund for clarity upon invoicing or auditing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024. This is the standard practice for most grants we have accepted, and therefore, we will not vary from this practice in the future even if given permission to do so.

Corrective Action Plan: The Corporation will enhance internal control procedures to ensure that all cash disbursements are reviewed and approved by management before issuance. The procedure will involve: 1. Voucher Review Protocol: A checklist will be created to ensure that all disbursements are accompanied by documented approvals. This checklist will include verification of the approval by both management and legal counsel when necessary. 2. Management Approval: Disbursements, particularly those over $500,000, will require formal sign-off from the Chief Executive Officer and review by the Legal Department. 3. Training & Compliance: Staff will be trained on the updated process, and compliance will be regularly reviewed by the internal audit team. A report on adherence to these new procedures will be made available to the Board quarterly. 4. Verification of Prior Disbursement: Regarding the specific instance cited, management will review the process followed to verify that the review by Albanese and LDC counsel, as referenced in the email, was correctly documented. If this was indeed the case, a follow-up with the auditors will be initiated to clarify the discrepancy. Responsible Individual: Joseph Ninomiya - Chief Executive Officer Planned Date of Implementation: October 15, 2024

1)The duplicate invoice for $92,880.00 was removed from the Tracker worksheet which was submitted in 11/27/2023. 2)The duplicate invoice for $91,511.66 will be removed from the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024. 3)The discounts taken for early payment of contract labor invoices for a certain vendor will be corrected on the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024.

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward design controls to ensure formal documentation of approval of comparables is in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Home Forward will add clarifying language in our Shelter Plus Care (Continuum of Care) Program operating manual indicating need for staff to document who completed rent reasonableness reviews including signatures from program supervisors or department staff responsible for approving comparables when necessary as part of the rent reasonableness review. Additional staff training will be conducted during Shelter Plus Care and department team meetings. Name(s) of the contact person(s) responsible for corrective action: Ian Slingerland, Director of Homeless Initiatives and Supportive Housing Planned completion date for corrective action plan: 10/1/2024

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward implements a process to ensure exclusion checks are done prior to the execution of a contract. This process should include a system to ensure documentation is maintained in the files evidencing the date of the exclusion check as well as documented review and approval of the results of the exclusion check by program staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement has updated the Contract Request form to include a section for attesting yes or no for federal funds, also allowing for free form entry. After a discussion with DCR on situations where they are unsure if there will be HUD funding it was determined to treat all their Public Improvement projects as Davis Bacon projects and include all applicable steps throughout the solicitation process. We are doing a full background check on all contracts, which includes a sam.gov check. When the contracts come to the Contracts and Procurement Manager for final signature, a check will be made in the file to confirm the documents are present showing the sam.gov screen print was made and the Contracts and Procurement Manager will sign both the background check and the Contract at that time. Example attached. Name(s) of the contact person(s) responsible for corrective action: Celeste King Planned completion date for corrective action plan: June 1, 2024

Finding Number: 2023-001- Schedule of Expenditures of Federal Awards (SEFA) Preparation – Material Weakness Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the federal award to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. This includes properly identifying all federal awards subject to the Uniform Guidance and fairly presenting the required information in the schedule of expenditures of federal awards. Condition: Subsequent to the issuance of the Audit Report on the Consolidated Financial Statements and Supplementary Information for the year ended September 30, 2023, it was discovered that there was an omission of two federal grants with expenditures totaling $1,591,715 from the schedule of expenditures of federal awards. Cause: The Organization did not communicate with Care 1st Health Plan regarding the details of certain contracts to determine the amounts were subject to the Uniform Guidance and were to be included on the schedule of expenditures of federal awards. In addition, Care 1st Health Plan became the Regional Behavioral Health Authority for the Northern Arizona region effective October 1, 2022. Due to this transition, various changes occurred causing uncertainties with classifications of certain types of federal awards as subrecipient awards versus as contractor payments. Effect: The schedule of expenditures of federal awards was understated by $1,591,715, which resulted in the restatement of the previously issued schedule of expenditures of federal awards to correct the omission. Questioned Costs: Not applicable. Recommendation: We recommend that all funding contracts are carefully reviewed to determine whether amounts awarded should be classified as contractor payments or as subrecipient payments. If there is any uncertainty, we recommend that the Organization contact the funding source for clarification. Name of Contact Person: Mike Fett, CFO Phone Number: 602-265-8338 Anticipated Completion Date: September 30, 2024 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish procedures to review all contracts and to if necessary, to communicate with funding sources to ensure that receipts of federal funding are properly classified as being subrecipient versus contractor arrangements to ensure completeness of the Schedule of Expenditures of Federal Awards.

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 and July 10, 2024. Explanation: National CASA/GAL has consistently maintained policies and procedures to ensure FFATA reports are filed timely. Documentation of review/approval from a person separate from the person filing the FFATA report was not readily available in some instances, so procedures were updated to include maintenance of such review/approval. FFATA reports are required to be filed “by the end of the month following the month after the subaward obligation date”. National CASA/GAL filed FFATA reports to adhere to this deadline in compliance with what it understood to be the obligation date, understanding an obligation date could not occur prior to the grant period. This finding was noted in the 2022 audit which was issued August 13, 2024. The 2023 audit, completed in September 2024, included in its scope, the same FFATA reports from the same federal grant that had been reviewed in the 2022 audit and OJJDP/OCFO monitoring visit. National CASA/GAL did not have an opportunity between the 2022 and 2023 audits to cure this finding in practice until the issuance of new subrecipient awards in 2024.

Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement. Responsible Party: Vice President Finance Completion Date: November 30, 2024

Finding: Akron Children’s screening for suspension and debarment through the third-party vendor results does not include controls to ensure file completeness or accuracy. Corrective Action Plan: Akron Children’s implemented a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. Completion Date: December 31, 2023 Corrective Action Plan: Akron Children’s developed a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including independent review of the accuracy of file submissions. Completion Date: October 31, 2024 Corrective Action Plan: Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements. Completion Date: December 31, 2023 Resposible Party: Chief Legal Counsel

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2023-001 Coronavirus Local Fiscal Recovery– Assistance Listing No. 21.027 Recommendation: We recommend that the Authority implements a control to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Department has implemented several processes and procedures to ensure pass-through funds or sub-awards are reported timely and accurately in the SEFA. The new processes include (1) review of grant award letters to determine reporting requirements, (2) comparing the award letter against the Minutes of the City Council or County Commissioners meetings to ensure grants accepted during the year are disclosed as such on both ends, (3) confirmed with source Agency Single Audit requirements, (4) and the implementation of revenue source checklist that will identify the source of the funds, type of grant, program name and cluster title, name of federal funding agency, federal assisting listing number (formerly known as CFDA number), etc. Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please contact Hector Ordonez, Vice President of Finance and Administration at (817) 333-3421 or hordonez@fwhs.org.

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a secondary person review the reports and in a timely manner. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-004 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Significant Deficiency Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets and time and effort reports. Statement of Concurrence: We concur with the finding above. Corrective Action: Effective immediately, a time and effort reporting policy was implemented and sent to all staff to ensure that staff follow the process. This policy will be reviewed with all new staff during new hire orientation and annually. Timesheets will be reviewed and approved by direct supervisors on a weekly basis. HR will send a reminder to all staff on a weekly basis to complete all missing time worked. Employees are responsible for updating the timesheet for each work week in Paylocity. 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: August 26, 2024. Name of Contact Person: James Paine, Ph.D. Chief Executive Officer Tel. No.: (646) 678-6711 E-mail: jpaine@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call James Paine at (646) 678-6711. Sincerely yours, _________________________ James Paine, Ph.D. Chief Executive Officer

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-002 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) – Significant Deficiency Description of Finding: There was no evidence of review and approval by someone other than the preparer of the FFATA subawards that were submitted to the FSRS. The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). Statement of Concurrence: We concur with the finding above. Corrective Action: As of September 1, 2023, BCHN implemented a workflow where FFATA information will be reported to the FSRS upon receipt of the Notices of Award. In addition, as of September 9, 2024, the FFATA report will be reviewed by someone other than the preparer prior to submission and evidence of the approval maintained. Completion Date: September 9, 2024. Name of Contact Person: James Paine, Ph.D. Chief Executive Officer Tel. No.: (718) 405-4993 E-mail: jpaine@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call James Paine at (718) 405-4993. Sincerely yours, _________________________ James Paine, Ph.D. Chief Executive Officer

Finding Number: 2023-003 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is aware of the Federal requirements prohibiting non-federal entities from contracting with parties that are suspended or debarred. The County has reviewed the U.S. Department of the Treasury compliance and reporting guidance to ensure it checks SAM.gov exclusions, collects a certification, or adds a clause or condition to the covered transaction, prior to applying Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) funds. Anticipated Completion Date: SAM.gov searches are performed and documented prior to applying CSLFRF funds to all covered transactions, following August 2023.

Finding Number: 2023-002 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is aware that the annual Project and Expenditure Report submitted for Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) to the U.S. Treasury was done so incorrectly. The County has reviewed the U.S. Department of the Treasury guidance and form instructions to ensure it is correctly reporting its CSLFRF activity going forward. Anticipated Completion Date: The correction will be made on the Annual Project and Expenditure Report due in April 2024, for the reporting period ending March 31, 2024.

97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Management did not adequately document the review and approval of expenditures associated with Federal Emergency Management Agency grant. While all expenditures were found to be allowable and within the period of performance, documentation of management’s approval was not available. Management has implemented formal documentation processes to demonstrate review and approval has been performed. Contact Person: Jane Hardy, VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: October 1, 2024

93.493 Congressional Directives Complete documentation of vendor suspension and disbarment verification was not maintained. While outside vendor verification services were performed monthly, adequate documentation for all vendors is not provided, only vendors with suspension or disbarment issues are identified and communicated to management. Management will coordinate with appropriate departments to review federal provisions for grant procurement and adjust policies and procedures to comply. Management will work with appropriate departments and the outside vendor to identify all grant related vendors and request positive verification monthly. All grant project directors will be educated on the procurement requirements for all federal awards. Contact Person: Jane Hardy – VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: December 31, 2024

93.493 Congressional Directives Management did not document the level of effort of key personnel identified as Project Directors which were providing in-kind support to the grant program. Management will implement bi-weekly tracking of effort via Excel spreadsheet by key personnel related to these grant projects. The tracking of hours of effort will be maintained along with other grant related documentation by the grant management team. Management will continue to seek clarification with awarding agency to clarify if such tracking can be eliminated. Contact Person: Danielle Wesley, VP Network Service Delivery danielle.wesley@childrens.com 214-456-8988 Expected Completion Date: October 31, 2024

93.493 Congressional Directives Of the forty (40) payroll expenditures selected for testing, the System’s management did not perform the internal controls over the required allowability criteria for four (4) samples. Management will implement additional review and approval processes by having grant supported employees provide bi-weekly screenshots of timecards to their direct manager for review and approval and forwarded to grant program leadership for approval and documentation. Contact Person: Danielle Wesley, VP Network Service Delivery danielle.wesley@childrens.com 214-456-8988 Expected Completion Date: October 31, 2024

Finding Number: 2023-003 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Verifying that a new vendor has not been suspended or debarred is analyzed on a case-by-case basis depending on the Federal award. Doing this for each vendor for ARPA would significantly disrupt our A/P process with the limited number of staff we have. Analysis was done for each new ARPA Broadband grant awarded after the finding was issued in 2022, and for new vendors with significant project costs. Of the samples tested in 2023, some were paid prior to the completion of the 2022 audit, before the County was aware of the finding and corrective action could take place. Anticipated Completion Date: Immediately