Corrective Action Plans

Finding No.: 2019-016 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Contact Persons: Perlie Santos, Chief Financial Officer; Yuline Cruz, MIECHV Program Manager; Vincent Camacho, Grants Administrator; Cora Ada, Procurement Director. Corrective Action: CHCC concurs with the findings but not the questioned costs. Although not timely scanned and sent electronically to the Auditors, the Procurement Documents are available for testing. In fiscal year 2020, CHCC implemented the document routing repository for the procurement process using Laserfiche Forms. This will enable CHCC to warehouse all supporting documentation related to procurement activities and document the approval process. With the implementation of the Munis Financial Information System in January 2023, CHCC is now able to electronically attach scanned supporting documents to the vouchers through the Tyler Content Manager (TCM). This will allow for audit testing to be done by providing auditors view only access to CHCC Financial Information System. Proposed Completion Date: On-Going

Finding No.: 2019-011 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Award Number: 5U79SP020710-04 and 5H795M062879-02 Area: Procurement and Suspension and Debarment Questioned Costs: $183,926 Contact Persons: Perlie Santos, Chief Financial Officer; Reyna Saures, CGC Director; Vincent Camacho, Grants Administrator; Cora Ada, Procurement Director; Chellah Sablan, Comptroller. Corrective Action: CHCC concurs with the findings but not the questioned costs. Although not timely scanned and sent electronically to the Auditors, the Procurement Documents are available for testing. In Fiscal Year 2020, CHCC implemented the document routing repository for the procurement process using Laserfiche Forms. This will enable CHCC to warehouse all supporting documentation related to procurement activities and document the approval process. With the implementation of the Munis Financial Information System in January 2023, CHCC is now able to electronically attach scanned supporting documents to the vouchers through the Tyler Content Manager (TCM). This will allow for audit testing to be done by providing auditors view only access to CHCC Financial Information System. Proposed Completion Date: On-Going

Finding No.: 2019-007 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 5U79SM062447-04 Area: Procurement and Suspension and Debarment Questioned Costs: $23,500 Contact Persons: Perlie Santos, Chief Financial Officer; Reyna Saures, CGC Director; Vincent Camacho, Grants Administrator; Cora Ada, Procurement Director. Corrective Action: Condition 1 CHCC does not concur with the findings and the questioned costs. RFP19-CHCC/CHC-SOC-019 was published for Contract 686641, that supports Document 1475823 for $9,800. Document 1430779 was encumbered using 672067OM. This is a bridge obligation through an approved request for payment memorandum, while the contract was in progress. ITB 16-CHCC/CGC-002 was published for Contract 621100, that supports documents 1456419 for $850 and 1440996 for $850. Condition 2 and 3 CHCC does not concur with the findings and the questioned costs. The requested documentation was provided, however, CHCC acknowledges that the file sent referenced the Purchase Order numbers and the Document number (Payment Voucher Number). This may have resulted in auditors not properly associating the provided Purchase Orders to the selected payment vouchers. 2019-007 Finding No.: 2019-007, Continued With the implementation of the Munis Financial Information System in January 2023, CHCC is now able to electronically attach Purchase Orders to the Invoices and supporting documents are also electronically linked to the Purchase Order and invoices. This will allow for audit testing to be done by providing auditors view only access to CHCC Financial Information System. Condition 4 CHCC does not concur with the findings and the questioned costs. Although solicitations were not obtained for the car rental for the 4th year of the grant, CHCC believes that the vehicle rental agreement was competitively procured during the initial years of the rental. The agreement was rolled over annually to avoid disruption of service and program activity. To illustrate that, although no solicitation was obtained on the subsequent rental renewal, CHCC still ensures reasonableness of cost. For this agreement, the rental was even reduced from $950 per month to $900 per month on the 5th year of the agreement. Proposed Completion Date: Not applicable as CHCC does not concur with the findings.

We are creating a position and job description for a project manager who will work closely with the Controller and Executive Director. The project manager will be responsible for creating the bid packages, the contractor selection, managing the construction project, and documenting finaI resuIts of the project. The anticipated completion date for this corrective action is July 31, 2024.

Action Plan to Address Policy Updates and Implementation (Finding 2018-001): a. Review and Update Policies: Begin by conducting a comprehensive review of existing policies, particularly those related to procurement, suspension, and debarment. Ensure these policies align with the latest HRSA requirements and federal regulations. b. Engage a Policy Consultant: Seek the expertise of a policy consultant or legal counsel well-versed in healthcare compliance and HRSA regulations to assist in policy revision. c. Policy Training: Develop a training program to educate staff, especially key personnel like the CEO and CFO, on the updated policies. This training should emphasize the significance of compliance and the potential consequences of non-compliance. d. Implementation Oversight: Appoint a Compliance Officer responsible for overseeing the implementation of updated policies and procedures. This officer should regularly audit and monitor adherence to these policies. e. Documentation and Reporting: Implement a robust documentation system to track policy adherence and any deviations. Ensure that timely and accurate reports are generated for review by internal committees and the board. f. Board and Committee Involvement: Enhance board and committee involvement in the oversight of policy compliance. Provide regular updates and reports to these entities to keep them informed and engaged in the compliance process. g. Continuous Monitoring: Establish a continuous monitoring process to identify any policy-related deficiencies promptly. Regularly assess the effectiveness of policies and make necessary adjustments. h. External Audit: Schedule an external audit ahead of time by an independent auditor or agency to ensure objectivity and compliance with HRSA standards. i. Communication: Promote a culture of compliance through effective communication channels. Encourage employees at all levels to report potential violations or concerns without fear of retaliation. j. Periodic Review: Commit to a periodic review of policies, at least annually, to ensure they remain current and aligned with any evolving HRSA regulations or federal mandates.