Audit 13243

FINDING 2021-001 – Schedule of Expenditures of Federal Awards (SEFA) Material Weakness in Internal Control over Financial Reporting Material Weakness in Internal Control over Compliance Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions Award Number/Award Year – 93.243 / 2021 Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion Award Number/Award Year – 93.829 / 2021 Criteria or specific requirement – Office of Management and Budget’s (OMB) Uniform Guidance requires the auditee to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements that includes total federal awards expended for each individual federal program. Condition – The Organization improperly omitted the Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions and the Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion from its SEFA for the year ended June 30, 2021. Effect – Uniform Guidance places the responsibility for identifying major programs on the auditor, and the SEFA serves as the primary basis for the auditor’s major program determination. Appropriate major program determination by the auditor is dependent upon the accuracy and completeness of the information in the SEFA. The original SEFA was understated and incomplete as a result of the two SAMHSA programs noted above being omitted, and two major programs were not identified in the original audit. Questioned costs – None. Cause – After the SEFA was prepared, the Organization determined these two programs should be included after a comprehensive examination of contracts was performed by the revenue management team. Repeat Finding – No. Recommendation – We recommend the Organization update their SEFA preparation policies and procedures to ensure any new contracts are subject to review and properly identified for inclusion in the SEFA. We further recommend the SEFA be reviewed in detail by a knowledgeable person at the Organization to verify the SEFA is complete and accurate. Response – The Organization agrees with the recommendation and will implement these changes with the preparation of the June 30, 2022 schedule of expenditures of federal awards. Finding 2021-001, described in Section II of the schedule of findings and questioned costs, also represents a finding of material weakness in internal control over compliance. See finding reported above.

FINDING 2021-001 – Schedule of Expenditures of Federal Awards (SEFA) Material Weakness in Internal Control over Financial Reporting Material Weakness in Internal Control over Compliance Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions Award Number/Award Year – 93.243 / 2021 Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion Award Number/Award Year – 93.829 / 2021 Criteria or specific requirement – Office of Management and Budget’s (OMB) Uniform Guidance requires the auditee to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements that includes total federal awards expended for each individual federal program. Condition – The Organization improperly omitted the Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions and the Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion from its SEFA for the year ended June 30, 2021. Effect – Uniform Guidance places the responsibility for identifying major programs on the auditor, and the SEFA serves as the primary basis for the auditor’s major program determination. Appropriate major program determination by the auditor is dependent upon the accuracy and completeness of the information in the SEFA. The original SEFA was understated and incomplete as a result of the two SAMHSA programs noted above being omitted, and two major programs were not identified in the original audit. Questioned costs – None. Cause – After the SEFA was prepared, the Organization determined these two programs should be included after a comprehensive examination of contracts was performed by the revenue management team. Repeat Finding – No. Recommendation – We recommend the Organization update their SEFA preparation policies and procedures to ensure any new contracts are subject to review and properly identified for inclusion in the SEFA. We further recommend the SEFA be reviewed in detail by a knowledgeable person at the Organization to verify the SEFA is complete and accurate. Response – The Organization agrees with the recommendation and will implement these changes with the preparation of the June 30, 2022 schedule of expenditures of federal awards. Finding 2021-001, described in Section II of the schedule of findings and questioned costs, also represents a finding of material weakness in internal control over compliance. See finding reported above.

FINDING 2021-001 – Schedule of Expenditures of Federal Awards (SEFA) Material Weakness in Internal Control over Financial Reporting Material Weakness in Internal Control over Compliance Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions Award Number/Award Year – 93.243 / 2021 Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion Award Number/Award Year – 93.829 / 2021 Criteria or specific requirement – Office of Management and Budget’s (OMB) Uniform Guidance requires the auditee to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements that includes total federal awards expended for each individual federal program. Condition – The Organization improperly omitted the Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions and the Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion from its SEFA for the year ended June 30, 2021. Effect – Uniform Guidance places the responsibility for identifying major programs on the auditor, and the SEFA serves as the primary basis for the auditor’s major program determination. Appropriate major program determination by the auditor is dependent upon the accuracy and completeness of the information in the SEFA. The original SEFA was understated and incomplete as a result of the two SAMHSA programs noted above being omitted, and two major programs were not identified in the original audit. Questioned costs – None. Cause – After the SEFA was prepared, the Organization determined these two programs should be included after a comprehensive examination of contracts was performed by the revenue management team. Repeat Finding – No. Recommendation – We recommend the Organization update their SEFA preparation policies and procedures to ensure any new contracts are subject to review and properly identified for inclusion in the SEFA. We further recommend the SEFA be reviewed in detail by a knowledgeable person at the Organization to verify the SEFA is complete and accurate. Response – The Organization agrees with the recommendation and will implement these changes with the preparation of the June 30, 2022 schedule of expenditures of federal awards. Finding 2021-001, described in Section II of the schedule of findings and questioned costs, also represents a finding of material weakness in internal control over compliance. See finding reported above.

FINDING 2021-001 – Schedule of Expenditures of Federal Awards (SEFA) Material Weakness in Internal Control over Financial Reporting Material Weakness in Internal Control over Compliance Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions Award Number/Award Year – 93.243 / 2021 Federal agency – U.S. Department of Health and Human Services Identification of federal program – Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion Award Number/Award Year – 93.829 / 2021 Criteria or specific requirement – Office of Management and Budget’s (OMB) Uniform Guidance requires the auditee to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements that includes total federal awards expended for each individual federal program. Condition – The Organization improperly omitted the Substance Abuse and Mental Health Services Administration (SAMHSA) – Medication Assisted Treatment Expansion and Prescription Drug and Opioid Addictions and the Substance Abuse and Mental Health Services Administration (SAMHSA) – CCBHC Expansion from its SEFA for the year ended June 30, 2021. Effect – Uniform Guidance places the responsibility for identifying major programs on the auditor, and the SEFA serves as the primary basis for the auditor’s major program determination. Appropriate major program determination by the auditor is dependent upon the accuracy and completeness of the information in the SEFA. The original SEFA was understated and incomplete as a result of the two SAMHSA programs noted above being omitted, and two major programs were not identified in the original audit. Questioned costs – None. Cause – After the SEFA was prepared, the Organization determined these two programs should be included after a comprehensive examination of contracts was performed by the revenue management team. Repeat Finding – No. Recommendation – We recommend the Organization update their SEFA preparation policies and procedures to ensure any new contracts are subject to review and properly identified for inclusion in the SEFA. We further recommend the SEFA be reviewed in detail by a knowledgeable person at the Organization to verify the SEFA is complete and accurate. Response – The Organization agrees with the recommendation and will implement these changes with the preparation of the June 30, 2022 schedule of expenditures of federal awards. Finding 2021-001, described in Section II of the schedule of findings and questioned costs, also represents a finding of material weakness in internal control over compliance. See finding reported above.