2023-004 – Reporting
Corrective Action: CBNHC will implement the following corrective actions:
• CBNHC will immediately complete the SF-425 financial reports for all fiscal years through September 30, 2023, and thereafter, every quarter through the current fiscal year.
• CBNHC will actively communicate its status with the IHS Area Office regarding its progress towards the required deliverables.
• CBNHC will implement an executive leadership team who are collectively responsible for assuring regulatory compliance for the entity, which will be achieved through the timely sharing of important information.
• CBNHC’s Board of Directors will serve as governance over these requirements.
Person Responsible: The following individuals will be responsible for the above corrective action plan:
• Interim Finance Director/Chief Operations Officer (Volelle Zamora) – Is responsible for ensuring the timely completion of annual audits and for ensuring the SF-425 financial reports are submitted to IHS according to the deadlines established by the AFA.
• Chief Executive Officer (Derrick Watchman) – Is responsible for ensuring that the annual narrative reports are submitted to IHS according to the AFA. In addition, the CEO will initiate monthly progress meetings with IHS.
• Chief Executive Officer (Derrick Watchman), Chief Medical Officer (Sheryl O’Shea MD), Interim Finance Director/Chief Operations Officer (Volelle Zamora), Executive Administrative Assistant (Ophelia Mace), and Human Resource Director (Christina Chavez) – Will serve as the CBNHC executive leadership team and are collectively responsible for assuring that the required reporting and other compliance are achieved.
• Board of Directors (Kimberly Bruce, Lester Secatero, Harrison Platero) – Are responsible for CBNHC’s governance and will monitor compliance.
Completion Date: The annual narrative reports for fiscal year 2023 were completed as of December 31, 2023. The SF-425 reports were completed and submitted to IHS in July 2024. CBNHC is conducting frequent progress meetings with IHS regarding its requirements for financial reporting.