Audit 29875

FY End
2022-12-31
Total Expended
$4.75M
Findings
16
Programs
4
Organization: Open Door Health Center (MN)
Year: 2022 Accepted: 2023-09-26

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
37714 2022-001 Significant Deficiency Yes I
37715 2022-002 Significant Deficiency Yes I
37716 2022-001 Significant Deficiency Yes I
37717 2022-002 Significant Deficiency Yes I
37718 2022-001 Significant Deficiency Yes I
37719 2022-002 Significant Deficiency Yes I
37720 2022-001 Significant Deficiency Yes I
37721 2022-002 Significant Deficiency Yes I
614156 2022-001 Significant Deficiency Yes I
614157 2022-002 Significant Deficiency Yes I
614158 2022-001 Significant Deficiency Yes I
614159 2022-002 Significant Deficiency Yes I
614160 2022-001 Significant Deficiency Yes I
614161 2022-002 Significant Deficiency Yes I
614162 2022-001 Significant Deficiency Yes I
614163 2022-002 Significant Deficiency Yes I

Contacts

Name Title Type
EF9WAUNMAMB6 Jennifer Beckius Auditee
5073445507 Ryan Engebretson Auditor
No contacts on file

Notes to SEFA

Title: Basis of Presentation Accounting Policies: NOTE 2SUMMARY OF SIGNIFICANT ACCOUNTING POLICIESExpenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. Open Door Health Center has elected to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. De Minimis Rate Used: Y Rate Explanation: The auditee used the de minimis cost rate. NOTE 1BASIS OF PRESENTATIONThe accompanying schedule of expenditures of federal awards (the Schedule) includes the federal award activity of Open Door Health Center, under programs of the federal government for the year ended December 31, 2022. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Because the Schedule presents only a selected portion of the operations of Open Door Health Center, it is not intended to and does not present the financial position, results of operations, changes in net assets, or cash flows of Open Door Health Center.
Title: Other Matters Accounting Policies: NOTE 2SUMMARY OF SIGNIFICANT ACCOUNTING POLICIESExpenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. Open Door Health Center has elected to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. De Minimis Rate Used: Y Rate Explanation: The auditee used the de minimis cost rate. NOTE 3OTHER MATTERSAmount of Noncash Assistance NoneAmount of Insurance NoneAmount of Loans NoneAmount of Loan Guarantees NoneAmount Provided to Subrecipients None

Finding Details

2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-001 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Periods: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.320 states the non-Federal entity must have and use documented procurement procedures following specific requirements for different methods of procurement depending on size and type of purchase. Thresholds for these categories (micro-purchase, simplified acquisition threshold) refer to using the Federal Acquisition Regulations (FAR), unless a different threshold has been specifically approved. Specifically, under FAR multiple quotes are generally required for purchases over the micro-purchase threshold, or documentation should be maintained explaining why multiple quotes were not obtained. Condition: During our testing, we noted the Center did not have a properly documented procurement policy that met the federal requirements for the full year. The policy was revised in June 2022 to be in compliance. As a result there were vendors over the micro purchase threshold prior to the policy change that were tested where retained documentation was not sufficient to support procurement method or noncompetitive procurement in line with federal requirements. Context: During our testing, it was noted that through June 2022 the Center had documented procurement policy procedures, which described individuals and parties responsible throughout the procurement process; however, it did not contain all of the necessary elements, as required by federal regulations. Specifically, purchases under $25,000, but above the micro-purchase threshold, did not require multiple price quotes. Due to the Center's policy, the internal micro-purchase threshold is set at $25,000, so for purchases between $10,000 (maximum micro-purchase threshold without specific approval for a higher threshold), there was not documentation or support for multiple price quotes, or documentation on why sole source procurement was followed. There are also circumstances of vendors over $25,000 in total where noncompetitive procurement was utilized, but documentation wasn?t necessarily retained on why and how it fit within the Center?s policy and federal requirements. With adoption of the new policy during 2022 these thresholds were changed to be in line with federal requirements, and procedures implemented to properly document procurement method, cost analysis, and justification for noncompetitive procurement, as applicable. Cause: The Center had not yet fully updated their procurement policy to meet Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of documented procurement policies over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: Yes ? 2021-001 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support each procurement method. We also recommend implementing procedures to monitor vendor totals to identify situations where a vendor originally expected to be under a procurement threshold, subsequently exceeds it. In the event this happens, analysis and documentation would be necessary to support the continued use of the vendor. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the procurement policy to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.
2022-002 Federal Agency: United States Department of Health and Human Services Federal Program Title: Health Center Cluster Assistance Listing Numbers: 93.224/93.527 Award Period: March 1, 2021 through February 28, 2022, March 1, 2022 through February 28, 2023, April 1, 2021 through March 31, 2023. Type of Finding: ? Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria or specific requirement: The Code of Federal Regulations section 200.214 requires the Center to follow the nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The Center should have policies and procedures in place to ensure contracts or subaward are not provided to third parties that are suspended or disbarred. Condition: During our testing, we noted the Center did not have formal policies or procedures in place to determine if vendors have been suspended or disbarred prior to entering into a contract until June 2022 when the policy was created. Context: During our audit work performed, it was identified that prior to June 2022, the Center did not have a process to check the 'System for Award Management (SAM) Exclusions' or other procedures to ensure third parties were not suspended or disbarred, or retain related support. These procedures were implemented after the new policy was created in June 2022. As a result there were instances of vendors utilized prior to the new policy where documentation was not available to show the vendor being checked against exclusion lists. All vendors over $25,000 under the health center cluster grants were checked against the exclusion list at time of audit, and no exclusions were noted. Cause: The Center did not have a formal suspension and disbarment policy in place for the full year that met Uniform Guidance requirements. There was a prior year audit finding related to the procurement policy, but due to the timing of audit issuance, the corrective action was not able to be implemented back to the beginning of 2022. Effect: The lack of a formal suspension and debarment policy provides the opportunity for noncompliance due to transactions with suspended or disbarred parties. Repeat Finding: Yes ? 2021-002 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward.