Corrective Action Plans

Management concurs with the finding. Due to an administrative error, JCMC included certain ineligible patient clinical laboratory testing costs, recorded as bad debt expense, in federal grant expenditures. Although management consulted with the Program administrator, the County of Hudson, prior to seeking reimbursement and received approval to include these costs, JCMC acknowledges its responsibility to ensure federal funds are not used to reimburse unallowable services. Going forward, JCMC will strengthen its review process to exclude unallowable bad debt costs from grant expenditures. Management has reviewed the applicable Uniform Guidance cost principles with Program grant personnel and supporting analysts to reinforce compliance. Responsible Official: Alexander Filipak, VP Finance, Jersey City Medical Center Email: Alexander. Filipiak@rwjbh.org. Anticipated Completion Date: December 31, 2026

This error resulted from staff turnover and transition of the draw process to new accounting personnel. We will review the allocation of allowable costs and strengthen controls to ensure accurate cost accounting for future submissions. The error will be corrected in the August 2026 draw submission. The Controller and CFO are responsible for implementing and monitoring these corrective actions.

FINDING 2025-004 – Payroll Allocations Audit Finding Description: Audit procedures over expenditures revealed the following: For one (1) of forty (40) expenditure transactions tested, The Inner Voice, Inc. did not adequately track or review time and effort documentation for accuracy. For this selection, the time study used to allocate salary did not agree with the actual hours reported and paid. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Corrective Action Plan: Management will enhance policies and procedures related to time and effort reporting by strengthening review and approval processes for payroll allocations and providing additional staff training. These actions will improve consistency and reinforce internal controls over federal awards. Name of Contact Person Responsible for Corrective Action: Khurram Navaid, CFO/ Monika Mader, Exec. Manager Planned Completion Date: January 01, 2026

Planned Corrective Action: We removed all unallowable costs from our indirect cost pool to ensure full compliance with applicable cost principles. We implemented an additional layer of review during the preparation of our 2025 indirect cost rate proposal to identify and exclude any unallowable charges. We added a dedicated step to our monthly close process to review all new charges and determine whether any should be classified as unallowable. Anticipated Completion Date 12/31/2025. Responsible Contact Person: Katherine Page, Director of Finance