Finding: 2023-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-003 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be updated to ensure that employees time and effort reports that coincide with the Organization’s payroll cycle are maintained to document hours worked and that I-9 forms are obtained for all employees.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-003 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be updated to ensure that employees time and effort reports that coincide with the Organization’s payroll cycle are maintained to document hours worked and that I-9 forms are obtained for all employees.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-003 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be updated to ensure that employees time and effort reports that coincide with the Organization’s payroll cycle are maintained to document hours worked and that I-9 forms are obtained for all employees.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-004 Uniform Data System Report
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance, Reporting – Uniform Data System
Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the years ended December 31, 2022 and 2023, contained incorrect data for total federal grants. Federal grants were overstated in Table 9D of the UDS report by approximately $1,590,000 and $1,747,000, respectively.
Cause: The above exception resulted from errors in preparing Table 9D of the UDS report.
Effect: The DHHS reviews the UDS report during financial analysis of grant recipients. Errors in this data could cause incorrect financial analysis results and distorted performance indicators.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that a system should be developed to ensure that federal grants are correctly reported in the UDS report.
Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are correctly reported in the UDS report.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-004 Uniform Data System Report
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance, Reporting – Uniform Data System
Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the years ended December 31, 2022 and 2023, contained incorrect data for total federal grants. Federal grants were overstated in Table 9D of the UDS report by approximately $1,590,000 and $1,747,000, respectively.
Cause: The above exception resulted from errors in preparing Table 9D of the UDS report.
Effect: The DHHS reviews the UDS report during financial analysis of grant recipients. Errors in this data could cause incorrect financial analysis results and distorted performance indicators.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that a system should be developed to ensure that federal grants are correctly reported in the UDS report.
Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are correctly reported in the UDS report.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-004 Uniform Data System Report
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance, Reporting – Uniform Data System
Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the years ended December 31, 2022 and 2023, contained incorrect data for total federal grants. Federal grants were overstated in Table 9D of the UDS report by approximately $1,590,000 and $1,747,000, respectively.
Cause: The above exception resulted from errors in preparing Table 9D of the UDS report.
Effect: The DHHS reviews the UDS report during financial analysis of grant recipients. Errors in this data could cause incorrect financial analysis results and distorted performance indicators.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that a system should be developed to ensure that federal grants are correctly reported in the UDS report.
Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are correctly reported in the UDS report.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-005-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2022, were not submitted to the Federal Audit Clearinghouse until January 22, 2024, which was beyond the filing period of August 31, 2023.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2022 was a result of the auditor delaying audit procedures throughout 2023. Despite management’s attempts to obtain a final audit report, the audit report was not received by the Organization in a timely manner for filing with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported.
Context/Sampling: None
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-005-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2022, were not submitted to the Federal Audit Clearinghouse until January 22, 2024, which was beyond the filing period of August 31, 2023.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2022 was a result of the auditor delaying audit procedures throughout 2023. Despite management’s attempts to obtain a final audit report, the audit report was not received by the Organization in a timely manner for filing with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported.
Context/Sampling: None
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-005-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2022, were not submitted to the Federal Audit Clearinghouse until January 22, 2024, which was beyond the filing period of August 31, 2023.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2022 was a result of the auditor delaying audit procedures throughout 2023. Despite management’s attempts to obtain a final audit report, the audit report was not received by the Organization in a timely manner for filing with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported.
Context/Sampling: None
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-003 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be updated to ensure that employees time and effort reports that coincide with the Organization’s payroll cycle are maintained to document hours worked and that I-9 forms are obtained for all employees.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-003 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be updated to ensure that employees time and effort reports that coincide with the Organization’s payroll cycle are maintained to document hours worked and that I-9 forms are obtained for all employees.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-003 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be updated to ensure that employees time and effort reports that coincide with the Organization’s payroll cycle are maintained to document hours worked and that I-9 forms are obtained for all employees.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-004 Uniform Data System Report
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance, Reporting – Uniform Data System
Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the years ended December 31, 2022 and 2023, contained incorrect data for total federal grants. Federal grants were overstated in Table 9D of the UDS report by approximately $1,590,000 and $1,747,000, respectively.
Cause: The above exception resulted from errors in preparing Table 9D of the UDS report.
Effect: The DHHS reviews the UDS report during financial analysis of grant recipients. Errors in this data could cause incorrect financial analysis results and distorted performance indicators.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that a system should be developed to ensure that federal grants are correctly reported in the UDS report.
Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are correctly reported in the UDS report.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-004 Uniform Data System Report
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance, Reporting – Uniform Data System
Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the years ended December 31, 2022 and 2023, contained incorrect data for total federal grants. Federal grants were overstated in Table 9D of the UDS report by approximately $1,590,000 and $1,747,000, respectively.
Cause: The above exception resulted from errors in preparing Table 9D of the UDS report.
Effect: The DHHS reviews the UDS report during financial analysis of grant recipients. Errors in this data could cause incorrect financial analysis results and distorted performance indicators.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that a system should be developed to ensure that federal grants are correctly reported in the UDS report.
Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are correctly reported in the UDS report.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-004 Uniform Data System Report
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance, Reporting – Uniform Data System
Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the years ended December 31, 2022 and 2023, contained incorrect data for total federal grants. Federal grants were overstated in Table 9D of the UDS report by approximately $1,590,000 and $1,747,000, respectively.
Cause: The above exception resulted from errors in preparing Table 9D of the UDS report.
Effect: The DHHS reviews the UDS report during financial analysis of grant recipients. Errors in this data could cause incorrect financial analysis results and distorted performance indicators.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that a system should be developed to ensure that federal grants are correctly reported in the UDS report.
Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are correctly reported in the UDS report.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-005-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2022, were not submitted to the Federal Audit Clearinghouse until January 22, 2024, which was beyond the filing period of August 31, 2023.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2022 was a result of the auditor delaying audit procedures throughout 2023. Despite management’s attempts to obtain a final audit report, the audit report was not received by the Organization in a timely manner for filing with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported.
Context/Sampling: None
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-005-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2022, were not submitted to the Federal Audit Clearinghouse until January 22, 2024, which was beyond the filing period of August 31, 2023.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2022 was a result of the auditor delaying audit procedures throughout 2023. Despite management’s attempts to obtain a final audit report, the audit report was not received by the Organization in a timely manner for filing with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported.
Context/Sampling: None
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025
Finding: 2023-005-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2022, were not submitted to the Federal Audit Clearinghouse until January 22, 2024, which was beyond the filing period of August 31, 2023.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2022 was a result of the auditor delaying audit procedures throughout 2023. Despite management’s attempts to obtain a final audit report, the audit report was not received by the Organization in a timely manner for filing with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported.
Context/Sampling: None
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: February 28, 2025