Audit 316511

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.