2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
Finding 2022-005: Compliance with Reporting Requirements
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
COVID-19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution–
Assistance Listing No. 93.498
Compliance Findings: Reporting (L)
Criteria: Under the Provider Relief Fund Program, providers are required to submit reporting
to the Health Resources Services Administration (HRSA). For Periods 3 and 4, providers are
required to calculate and report ‘Total Lost Revenues for the Period of Availability’ and
‘Total Payments Used for Lost Revenues in the Previous Report Period’. Additionally,
providers are required to submit various personnel, patient and facility metrics.
Additionally, per 2 CFR 200.303, a non-Federal entity must establish and maintain effective
internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes,
regulations, and the terms and conditions of the award. These internal controls should be in
compliance with guidance in “Standards for Internal Control in the Federal Government”
issued by the Comptroller General of the United States or the “Internal Control Integrated
Framework”, issued by the Committee of Sponsoring Organizations of the Treadway
Commission (COSO).
Condition: During our audit, it was noted that the amounts reported for ‘Total Payments Used
for Lost Revenues in the Previous Reporting Period’ did not properly report the $662,986 that
was claimed under Periods 1 and 2 of the program. Additionally, we were unable to test the
accuracy of the personnel, patient and facility metrics reported as the documentation to
support this information was unable to be located.
Cause: Internal controls in place were not sufficient to ensure accurate information, regarding
Period 1 and Period 2 ‘Lost Revenues Used’, was reported or that underlying records to
support information reported was retained.
Effect: The Organization is not in compliance with reporting requirements.
Context: Total ‘Lost Revenues for the Period of Availability’ significantly exceeds both the
‘Payments used for Lost Revenues in the Previous Reporting Period’ and the ‘Total Payments Used for Lost Revenues in the Current Reporting Period’. Therefore, the error is not
considered to be a material noncompliance with programmatic requirements.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that the Organization review and improve its internal
control procedures to ensure accuracy of information reported. Additionally, we recommend
the Organization ensure internal control procedures include retaining documentation to
substantiate the information reported.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure records are retained in
accordance with policy. Additional details can be found in the Organization’s Corrective
Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
Finding 2022-003: Lack of Documented Procurement Procedures
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Section 223 Demonstration Programs for Improving Community Mental Health Services –
Assistance Listing No. 93.829
Compliance Findings: Procurement and Suspension and Debarment (I)
Criteria: The Standard Terms and Conditons for all SAMHSA’s awards requires that grantees
comply with Title 2 U.S. Code of Federal Regulation (CFR) section 200.318 through 200.321. In
accordance with 2 CFR section 200.320, a non-federal entity must have and use documented
procurement procedures, consistent with the standards of 2 CFR section 200.317 through 200.320
for any method of procurement used for the acquisition of property or services required under a
federal award or sub-award.
Condition: The Organization does not have documented procurement procedures that incorporate
all the requirements of 2 CFR section 200.317 through 200.320.
Cause: Unknown.
Questioned Costs: None.
Effect: The Organization is not in compliance with 2 CFR section 200.320 or the terms of the
grant agreement.
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that the Organization adopt a written procurement policy
which includes all requirements of 2 CFR section 200.317 through 200.320.
Views of Responsible Officials: The Organization agrees with the finding and will adopt a
documented procurement policy consistent with the standards of 2 CFR section 200.317 through
200.320 to use for procurement of the acquisition of property or services required under federal
awards or sub-awards. Additional details can be found in the Organization’s Corrective Action
Plan.
Finding 2022-004: Compliance with Reporting Requirements
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Section 223 Demonstration Programs for Improving Community Mental Health Services –
Assistance Listing No. 93.829
Compliance Findings: Reporting (L)
Criteria: Per the terms of the Award Notice, grantees are required to submit certain financial
reports and programmatic reports by specified due dates.
Additionally, per 2 CFR 200.303, a non-Federal entity must establish and maintain effective
internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes,
regulations, and the terms and conditions of the award. These internal controls should be in
compliance with guidance in “Standards for Internal Control in the Federal Government”
issued by the Comptroller General of the United States or the “Internal Control Integrated
Framework”, issued by the Committee of Sponsoring Organizations of the Treadway
Commission (COSO).
Condition: During our audit, it was determined that one of two financial reports selected for
testing was not submitted and two of the three reports selected for testing were not submitted
by the specified due date.
In addition, it was discovered that evidence to document reports are reviewed and approved
prior to submittal is not maintained by the Organizatoin. Per COSO, segregation of duties
should exist between those preparing and those reviewing and filing required reports. Best
practices would include ensuring adequate supporting evidence exists to substantiate controls
are being followed and all required reports are being submitted and submitted by their
specified due dates.
Cause: Internal controls were not in place to ensure reports were submitted by the specified
due date and processes were not in place to ensure internal control procedures over review of
reporting sbumissions were documented and retained.
Effect: The Organization is not in compliance with reporting requirements.
Context: During our audit, the Organization had indicated that their internal control
procedures include a review of reporting submissions, however the auditor was unable to
substantiate statements made due to lack of supporting evidence and due to staff turnover at
the organization.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that the Organization review and improve its internal
control procedures to ensure compliance with reporting requirements. Additionally, we
recommend the Organization ensure internal control procedures include retaining
documentation of the procedures performed.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
Finding 2022-005: Compliance with Reporting Requirements
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
COVID-19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution–
Assistance Listing No. 93.498
Compliance Findings: Reporting (L)
Criteria: Under the Provider Relief Fund Program, providers are required to submit reporting
to the Health Resources Services Administration (HRSA). For Periods 3 and 4, providers are
required to calculate and report ‘Total Lost Revenues for the Period of Availability’ and
‘Total Payments Used for Lost Revenues in the Previous Report Period’. Additionally,
providers are required to submit various personnel, patient and facility metrics.
Additionally, per 2 CFR 200.303, a non-Federal entity must establish and maintain effective
internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes,
regulations, and the terms and conditions of the award. These internal controls should be in
compliance with guidance in “Standards for Internal Control in the Federal Government”
issued by the Comptroller General of the United States or the “Internal Control Integrated
Framework”, issued by the Committee of Sponsoring Organizations of the Treadway
Commission (COSO).
Condition: During our audit, it was noted that the amounts reported for ‘Total Payments Used
for Lost Revenues in the Previous Reporting Period’ did not properly report the $662,986 that
was claimed under Periods 1 and 2 of the program. Additionally, we were unable to test the
accuracy of the personnel, patient and facility metrics reported as the documentation to
support this information was unable to be located.
Cause: Internal controls in place were not sufficient to ensure accurate information, regarding
Period 1 and Period 2 ‘Lost Revenues Used’, was reported or that underlying records to
support information reported was retained.
Effect: The Organization is not in compliance with reporting requirements.
Context: Total ‘Lost Revenues for the Period of Availability’ significantly exceeds both the
‘Payments used for Lost Revenues in the Previous Reporting Period’ and the ‘Total Payments Used for Lost Revenues in the Current Reporting Period’. Therefore, the error is not
considered to be a material noncompliance with programmatic requirements.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that the Organization review and improve its internal
control procedures to ensure accuracy of information reported. Additionally, we recommend
the Organization ensure internal control procedures include retaining documentation to
substantiate the information reported.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure records are retained in
accordance with policy. Additional details can be found in the Organization’s Corrective
Action Plan.
2022-001: Late Filing of the Data Collection Form
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Condition: Range Mental Health Center, Inc. and Subsidiary did not submit its single audit
reporting package to the Federal Audit Clearinghouse within the required time frame.
Criteria: 2 CFR 200.328 establishes requirements for financial grant reporting by a nonfederal
entity. The Organization must report financial information as required by the terms
and conditions of the federal award. 2 CFR 200.512(a) requires the audit reporting package
and data collection form to be submitted to the Federal Audit Clearinghouse the earlier of 30
days after the reports are received from the auditors or nine months after the end of the audit
period.
Cause: Employee turnover in the finance department resulted in financial and program data
not being ready for the financial and single audits on a timely basis.
Effect: The Organization is not in compliance with timely reporting requirements.
Questioned Costs: $0
Context: Range Mental Health Center, Inc. and Subsidiary did not submit its year ended
December 31, 2021 audit reporting package to the Federal Audit Clearinghouse until April 4,
2023, and did not meet the nine month reporting requirement for the year ended December 31,
2022.
Recommendation: We recommend Range Mental Health Center, Inc. and Subsidiary continue
efforts to develop internal control policies and procedures over financial activities to ensure
that its financial and program data is ready for the financial and single audits on a timely
basis.
Views of Responsible Officials and Planned Corrective Actions: We agree with this finding
and have outsosurced its CFO function to improve the timeliness of financial activities.
Additional details can be found in the Organization’s Corrective Action Plan.
Finding 2022-002: Identification of Federal Funds for Purposes of Assembling the
Schedule of Expenditures of Federal Awards (SEFA)
All Federal programs included in the Schedule of Expenditures of Federal Awards
Compliance Findings: Other (P)
Criteria: Per 2 CFR 200.510(b) Schedule of expenditures of Federal awards, “the auditee
must prepare a schedule of expenditures of Federal awards for the period covered by the
auditee's financial statements which must include the total Federal awards expended as
determined in accordance with 2 CFR 200.502, Basis for determining Federal awards
expended. While the auditor is able to assist with SEFA preparation, management remains
responsible for identifying all federal expenditures to enable the preparation of a complete and
accurate SEFA.
Condition: Management was unable to provide a complete listing of federal expenditures at
the start of audit fieldwork.
Cause: Internal controls were not in place to ensure all relevant information was captured and
reported in SEFA preparation.
Effect: By not having proper controls over SEFA preparation at the beginning of the audit,
there is a risk that the SEFA will not reflect all the federal awards subject to the Uniform
Guidance, which could lead to an incorrect major program determination and a substandard
single audit.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that Range Mental Health Center, Inc. and Subsidiary
implement internal controls to ensure there is an adequate communication and review process
in place to capture all federal awards expended at the correct amounts in accordance with the
criteria above.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.
Finding 2022-003: Lack of Documented Procurement Procedures
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Section 223 Demonstration Programs for Improving Community Mental Health Services –
Assistance Listing No. 93.829
Compliance Findings: Procurement and Suspension and Debarment (I)
Criteria: The Standard Terms and Conditons for all SAMHSA’s awards requires that grantees
comply with Title 2 U.S. Code of Federal Regulation (CFR) section 200.318 through 200.321. In
accordance with 2 CFR section 200.320, a non-federal entity must have and use documented
procurement procedures, consistent with the standards of 2 CFR section 200.317 through 200.320
for any method of procurement used for the acquisition of property or services required under a
federal award or sub-award.
Condition: The Organization does not have documented procurement procedures that incorporate
all the requirements of 2 CFR section 200.317 through 200.320.
Cause: Unknown.
Questioned Costs: None.
Effect: The Organization is not in compliance with 2 CFR section 200.320 or the terms of the
grant agreement.
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that the Organization adopt a written procurement policy
which includes all requirements of 2 CFR section 200.317 through 200.320.
Views of Responsible Officials: The Organization agrees with the finding and will adopt a
documented procurement policy consistent with the standards of 2 CFR section 200.317 through
200.320 to use for procurement of the acquisition of property or services required under federal
awards or sub-awards. Additional details can be found in the Organization’s Corrective Action
Plan.
Finding 2022-004: Compliance with Reporting Requirements
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Section 223 Demonstration Programs for Improving Community Mental Health Services –
Assistance Listing No. 93.829
Compliance Findings: Reporting (L)
Criteria: Per the terms of the Award Notice, grantees are required to submit certain financial
reports and programmatic reports by specified due dates.
Additionally, per 2 CFR 200.303, a non-Federal entity must establish and maintain effective
internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes,
regulations, and the terms and conditions of the award. These internal controls should be in
compliance with guidance in “Standards for Internal Control in the Federal Government”
issued by the Comptroller General of the United States or the “Internal Control Integrated
Framework”, issued by the Committee of Sponsoring Organizations of the Treadway
Commission (COSO).
Condition: During our audit, it was determined that one of two financial reports selected for
testing was not submitted and two of the three reports selected for testing were not submitted
by the specified due date.
In addition, it was discovered that evidence to document reports are reviewed and approved
prior to submittal is not maintained by the Organizatoin. Per COSO, segregation of duties
should exist between those preparing and those reviewing and filing required reports. Best
practices would include ensuring adequate supporting evidence exists to substantiate controls
are being followed and all required reports are being submitted and submitted by their
specified due dates.
Cause: Internal controls were not in place to ensure reports were submitted by the specified
due date and processes were not in place to ensure internal control procedures over review of
reporting sbumissions were documented and retained.
Effect: The Organization is not in compliance with reporting requirements.
Context: During our audit, the Organization had indicated that their internal control
procedures include a review of reporting submissions, however the auditor was unable to
substantiate statements made due to lack of supporting evidence and due to staff turnover at
the organization.
Questioned Costs: $0
Identification of Repeat Finding: Not a repeat finding.
Recommendation: We recommend that the Organization review and improve its internal
control procedures to ensure compliance with reporting requirements. Additionally, we
recommend the Organization ensure internal control procedures include retaining
documentation of the procedures performed.
Views of Responsible Officials and Corrective Action Plan: Management agrees with this
finding and is in the process of developing internal controls to ensure timely and appropriate
actions are made on the deficiency noted. Additional details can be found in the
Organization’s Corrective Action Plan.