Finding 1241591 (2025-002)

CORRECTIVE ACTION PLAN September 25, 2026 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2025 The findings from the December 31, 2025 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, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410 and H8N53897 for 2025 Finding 2025-002 – 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 and Expected Date of Correction Identified Issue: Brooklyn Plaza Medical Center identified a need to strengthen the consistent application and documentation of the Sliding Fee Discount Program (SFDP), including front-end staff processes related to patient eligibility, documentation, and collection of applicable fees, as well as back-end billing processes to ensure that sliding fee adjustments and write-offs are applied accurately and consistently. Corrective Action Brooklyn Plaza Medical Center will implement a standardized training, monitoring, and reconciliation process to ensure appropriate administration of the Sliding Fee Discount Program from patient registration through final account reconciliation. This will be implemented by December 2026. Front Desk Training and Standardization All Front Desk/Patient Services staff will receive mandatory training on the Sliding Fee Discount Program. Training will include: • Reviewing the current Sliding Fee Discount Program policy and fee schedule. • Determining and documenting household size and income in accordance with established policy. • Identifying patients who may qualify for the Sliding Fee Discount Program. • Properly completing and maintaining required eligibility documentation. • Applying the appropriate sliding fee category based on established income guidelines. • Communicating the program and applicable patient responsibility clearly and consistently to patients. • Ensuring appropriate information is entered into the electronic health record/practice management system so that billing can process the account correctly. Training will be incorporated into the onboarding process for new Front Desk staff and reinforced through periodic refresher training. Billing and Write-Off Reconciliation The Billing/Revenue Cycle team will establish a back-end review process to ensure that accounts approved for the Sliding Fee Discount Program are adjusted appropriately. Billing staff will verify that: • The correct sliding fee category has been applied. • Patient responsibility is consistent with the approved sliding fee schedule. • Applicable contractual adjustments and sliding fee write-offs are accurately posted. • Sliding fee balances are not incorrectly transferred to patient responsibility or collection activity. • Any discrepancies identified between front-end documentation and back-end billing are corrected promptly. Billing will also conduct periodic reconciliation of sliding fee accounts to identify inappropriate balances, missed adjustments, or incorrect write-offs. Monitoring and Quality Assurance Management will conduct routine audits of a sample of Sliding Fee Discount Program accounts to confirm compliance at both the front and back end. Audit findings will be reviewed with Patient Services and Billing leadership, and any identified deficiencies will result in immediate correction and additional staff education as necessary. The organization will monitor compliance on an ongoing basis to ensure that the corrective action is sustained and that eligible patients consistently receive the appropriate sliding fee discount. Responsible Parties: Practice Administration/Patient Services Leadership Revenue Cycle/Billing Leadership Finance Compliance Expected Outcome: Brooklyn Plaza Medical Center will have a standardized and auditable process that ensures Sliding Fee Discount Program eligibility is appropriately determined and documented at the front end and that corresponding billing adjustments and write-offs are accurately reflected on the back end. If the Health Resources and Services Administration has questions regarding this plan, please call Philip J. Onorato, Chief Executive Officer at 718-596-9800, ext. 205.