Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS
Report, and Budget Progress Reports (BPR) in accordance with established requirements and
deadlines.
Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award
No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for
Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023.
Cause: During the year, there was turnover in the accounting department.
Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Questioned costs: n/a
Context: Five reports submitted during the year were selected for testing.
Repeat Finding: 2022‐001
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant‐related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports
Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and
Debarment
Health Center Program Cluster
CFDA No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438 and H8FCS40427
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 ‐200.326 and to follow this policy when procuring goods and services.
Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids were not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Health Organization’s procurement,
suspension and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.
Repeat Finding: n/a
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Procedures will be
developed and staff will be trained to ensure future procurement, suspension and debarment
transactions are identified and documentation is maintained to support the evaluation.