U.S. Department of Health and Human Services
Federal Financial Assistance Listing Number 93.829 Section 223 Demonstration
Programs to Improve Community Mental Health Services ‐ 6H79SM083306‐01M002
Cash Management and Reporting
Significant Deficiency in Internal Control over Compliance
Criteria: The OMB Compliance Supplement requires that non‐federal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements.
Condition: During our testing of reimbursement requests and reporting, there was no documentation available for the review and approval procedures performed.
Cause: The Organization did not have an adequate internal control policy to require the documentation of the reimbursement requests’ and reports review and approval.
Effect: Inaccurate reimbursement requests or reports may be prepared, which could lead to amounts received or reported in error.
Questioned Costs: None.
Context/Sampling: There was a total of two reimbursement requests and one report prepared for the year ended June 30, 2023 all of which were selected for testing. None of the reimbursement requests or reports contained documentation of the request being reviewed or approved.
Repeat Finding from Prior Year(s): Yes for cash management, but no for reporting.
Recommendation: We recommend the Organization enhance internal control policies to require documentation of the review and approval procedures performed in the preparation and review of reimbursement requests and reports.
Views of Responsible Individuals: Management agrees with the finding.
U.S. Department of Health and Human Services
Federal Financial Assistance Listing Number 93.829 Section 223 Demonstration
Programs to Improve Community Mental Health Services ‐ 6H79SM083306‐01M002
Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance
Significant Deficiency in Internal Control over Compliance
Criteria: The OMB Compliance Supplement requires that non‐federal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements.
Condition: During our testing, there was no documentation of review and approval of employee timecards for a portion of the sample selected.
Cause: The Organization did not have an adequate internal control policy to ensure review and approval of employee timecards was documented.
Effect: The lack of adequate policies governing employee timecards increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner.
Questioned Costs: None.
Context/Sampling: A nonstatistical sample of 65 expenditures submitted for reimbursement were selected for testing. Of these 65, 1 did not show evidence of proper review and approval prior to payment.
Repeat Finding from Prior Year(s): Yes.
Recommendation: We recommend that the Organization enhance internal control policies to ensure all employee timecards are reviewed and approved prior to payment to ensure that all payments are necessary and correct.
Views of Responsible Individuals: Management agrees with the finding.
U.S. Department of Health and Human Services
Federal Financial Assistance Listing Number 93.829 Section 223 Demonstration
Programs to Improve Community Mental Health Services ‐ 6H79SM083306‐01M002
Procurement and Suspension and Debarment
Significant Deficiency in Internal Control over Compliance
Criteria: The Uniform Guidance, Section 200.303 Internal Controls, requires the non‐federal entity must establish and maintain effective internal controls over federal awards that provide reasonable assurance that awards are being managed in compliance with
federal statutes, regulations and the terms and conditions of the federal award.
The non‐Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non‐ Federal entity's documented procurement procedures must conform to the procurement standards identified in §§ 200.318 through 200.327.
Condition: The Organization did not have a written procurement policy that was consistent with Federal, State, local, and tribal laws and regulations.
Cause: There is a lack of controls over the written procurement, suspension and debarment policy.
Effect: Failure to maintain a written procurement policy that was consistent with Federal, State, local, and tribal laws and regulations may result in disallowed costs.
Questioned Costs: None.
Context/Sampling: EB reviewed the procurement, suspension and debarment policy.
Repeat Finding from Prior Year(s): Yes.
Recommendation: We recommend that management implement a written procurement, suspension and debarment policy that meets Federal, State, local, and tribal laws and regulations. We also recommend that management review this policy regularly to confirm that it meets the requirements.
Views of Responsible Individuals: Management agrees with the finding.
U.S. Department of Health and Human Services
Federal Financial Assistance Listing Number 93.829 Section 223 Demonstration
Programs to Improve Community Mental Health Services ‐ 6H79SM083306‐01M002
Cash Management and Reporting
Significant Deficiency in Internal Control over Compliance
Criteria: The OMB Compliance Supplement requires that non‐federal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements.
Condition: During our testing of reimbursement requests and reporting, there was no documentation available for the review and approval procedures performed.
Cause: The Organization did not have an adequate internal control policy to require the documentation of the reimbursement requests’ and reports review and approval.
Effect: Inaccurate reimbursement requests or reports may be prepared, which could lead to amounts received or reported in error.
Questioned Costs: None.
Context/Sampling: There was a total of two reimbursement requests and one report prepared for the year ended June 30, 2023 all of which were selected for testing. None of the reimbursement requests or reports contained documentation of the request being reviewed or approved.
Repeat Finding from Prior Year(s): Yes for cash management, but no for reporting.
Recommendation: We recommend the Organization enhance internal control policies to require documentation of the review and approval procedures performed in the preparation and review of reimbursement requests and reports.
Views of Responsible Individuals: Management agrees with the finding.
U.S. Department of Health and Human Services
Federal Financial Assistance Listing Number 93.829 Section 223 Demonstration
Programs to Improve Community Mental Health Services ‐ 6H79SM083306‐01M002
Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance
Significant Deficiency in Internal Control over Compliance
Criteria: The OMB Compliance Supplement requires that non‐federal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements.
Condition: During our testing, there was no documentation of review and approval of employee timecards for a portion of the sample selected.
Cause: The Organization did not have an adequate internal control policy to ensure review and approval of employee timecards was documented.
Effect: The lack of adequate policies governing employee timecards increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner.
Questioned Costs: None.
Context/Sampling: A nonstatistical sample of 65 expenditures submitted for reimbursement were selected for testing. Of these 65, 1 did not show evidence of proper review and approval prior to payment.
Repeat Finding from Prior Year(s): Yes.
Recommendation: We recommend that the Organization enhance internal control policies to ensure all employee timecards are reviewed and approved prior to payment to ensure that all payments are necessary and correct.
Views of Responsible Individuals: Management agrees with the finding.
U.S. Department of Health and Human Services
Federal Financial Assistance Listing Number 93.829 Section 223 Demonstration
Programs to Improve Community Mental Health Services ‐ 6H79SM083306‐01M002
Procurement and Suspension and Debarment
Significant Deficiency in Internal Control over Compliance
Criteria: The Uniform Guidance, Section 200.303 Internal Controls, requires the non‐federal entity must establish and maintain effective internal controls over federal awards that provide reasonable assurance that awards are being managed in compliance with
federal statutes, regulations and the terms and conditions of the federal award.
The non‐Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non‐ Federal entity's documented procurement procedures must conform to the procurement standards identified in §§ 200.318 through 200.327.
Condition: The Organization did not have a written procurement policy that was consistent with Federal, State, local, and tribal laws and regulations.
Cause: There is a lack of controls over the written procurement, suspension and debarment policy.
Effect: Failure to maintain a written procurement policy that was consistent with Federal, State, local, and tribal laws and regulations may result in disallowed costs.
Questioned Costs: None.
Context/Sampling: EB reviewed the procurement, suspension and debarment policy.
Repeat Finding from Prior Year(s): Yes.
Recommendation: We recommend that management implement a written procurement, suspension and debarment policy that meets Federal, State, local, and tribal laws and regulations. We also recommend that management review this policy regularly to confirm that it meets the requirements.
Views of Responsible Individuals: Management agrees with the finding.