Audit 354688

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 U.S. Department of Treasury Missouri Primary Care Association Criteria or specific requirement – Reporting (2 CFR 200.329) Condition – The Organization’s internal controls over compliance were not able to ensure progress reporting required to be submitted to the pass-through entity was completed timely. Cause – The Organization does not have internal controls over compliance in place to ensure all grant reporting requirements are satisfied timely. Effect or potential effect – The Organization did not submit the required quarterly and annual performance reports in a timely manner. Questioned costs – None Context – The Organization is required to submit quarterly status reports and an annual performance report to the pass-through entity in a timely manner. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should consider implementing a grant reporting calendar for all grants with reporting requirements. Views of responsible officials and planned corrective actions – Our quarterly status progress report was inadvertently sent two days past the due date in to our state office. We have corrected this by implementing controls by placing the quarterly due dates on our calendars so these due dates are no longer overlooked going forward.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 U.S. Department of Treasury Missouri Primary Care Association Criteria or specific requirement – Procurement (2 CFR 200.319 and 2 CFR 200.320) Condition – The Organization’s internal controls over compliance were not sufficient to ensure the appropriate procurement method was utilized based on the value of the procurement transaction or to ensure procurement transactions were conducted in a manner that provided full and open competition. Cause – The Organization did not follow its policy when procuring services during the pre-construction phase of a project later funded by federal grants. Effect or potential effect – A contract for services was entered into during 2022 with estimated fees in excess of the threshold requiring a formal procurement method. The request for proposal did not allow for full and open competition as the Organization did not publicly request proposals or bids and only one proposal was obtained. Services purchased in 2024 under this contract may not have been obtained in the most effective manner. Questioned costs – Unknown Context – A sample of one procurement totaling $336,274 was tested out of a population of three procurements. The sample was not, and is not intended to be, statistically valid. The Organization’s procurement records were insufficient in accordance with the Organization’s procurement policy and Uniform Guidance. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should educate employees on its procurement policy, which is compliant with Uniform Guidance. The Organization should also implement additional internal controls, such as the creation of a standard form or template for purchase orders, contracts, requests for proposals/bids, cost/price analyses, bid evaluation, etc., to ensure compliance with its procurement policy and that procurement records sufficient to detail the history of each procurement transaction are maintained. Views of responsible officials and planned corrective actions – This error occurred during fiscal year 2022, when the architect for an upcoming project was chosen. We are in a very rural area, where architects are not easy to come by. For this project, we had decided to utilize a local firm we had a good track record with. We presented it to our board for approval, and it was approved by them at that time so we originally had thought we could justify with having them as a sole source vendor. At the time, the total amount of the project was unknown, and has even changed significantly since that date. However, come to find out, due to the size of the project it should have been bid out. We have revised our procurement policy since this date and have educated all staff on proper procurement procedures.

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Health Center Program Cluster – Assistance Listing No. 93.224 U.S. Department of Health and Human Services Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Criteria or specific requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Cause – The Organization obtained a drawdown for a deposit for a project that was ultimately suspended beyond the period of performance. When the project was paused, the Organization was unable to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Effect or potential effect – Due to reallocation of grant expenditures, the Organization may earn interest on the advance drawdown. Questioned costs – None Context – Because of a change in the timeline for estimated completion of a project included in the HRSA-approved grant budget to outside the period of performance, other grant expenditures were identified. The Organization was not able to identify sufficient eligible expenditures incurred within the audit period and disbursed before the drawdown date. Management identified the need to contact the grantor for guidance and alert auditors to noncompliance resulting from the resulting advance drawdown. Management also calculated the amount of interest earned on advance draws to ensure none needed to be returned. The entire population of drawdowns was tested to quantify the impact of the advance drawdown and calculate interest earned on advance drawdowns. Interest earned on the advance drawdown was less than $500. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should continue monitoring projects funded by grants in an attempt to prevent advance drawdowns. Views of responsible officials and planned corrective actions – Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 U.S. Department of Treasury Missouri Primary Care Association Criteria or specific requirement – Reporting (2 CFR 200.329) Condition – The Organization’s internal controls over compliance were not able to ensure progress reporting required to be submitted to the pass-through entity was completed timely. Cause – The Organization does not have internal controls over compliance in place to ensure all grant reporting requirements are satisfied timely. Effect or potential effect – The Organization did not submit the required quarterly and annual performance reports in a timely manner. Questioned costs – None Context – The Organization is required to submit quarterly status reports and an annual performance report to the pass-through entity in a timely manner. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should consider implementing a grant reporting calendar for all grants with reporting requirements. Views of responsible officials and planned corrective actions – Our quarterly status progress report was inadvertently sent two days past the due date in to our state office. We have corrected this by implementing controls by placing the quarterly due dates on our calendars so these due dates are no longer overlooked going forward.

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 4 C14CS39926-01-06, September 1, 2020 – November 30, 2023 Award No. 4 H8FCS40544-01-03, April 1, 2021 – March 31, 2024 Award No. 1 H2ECS45559-01-01, May 1, 2022 – April 30, 2023 Award No. 6 H8HCS44994-02-02, September 1, 2022 – August 31, 2023 Award No. 4 H8GCS48199-01-01, December 1, 2022 – December 31, 2023 Award No. 6 H2ECS45559-02-03, May 1, 2023 – April 30, 2025 Award No. 1 H8LCS51638-01-00, September 1, 2023 – August 31, 2024 Award No. 5 H8HCS44994-03-00, September 1, 2023 – August 31, 2024 Award No. 6 H2ECS50103-01-02, September 1, 2023 – August 31, 2024 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (45 CFR 75.403 and 45 CR 75.421) Condition – Advertising costs unrelated to the performance of the Federal award were charged to grant. Questioned Costs – $1,685. Questioned costs were determined as the value of errors found in the sample of direct, non-payroll grant expenditures. Questioned costs by federal award identification number are: • Assistance Listing No. 93.224 Award No. 6 H8HCS44994-02-02 – $1,685 Context – A sample of 25 expenditures were tested out of a population of 289 direct, non-payroll grant expenditures. Samples were not, and were not intended to be, statistically valid. A portion of two expenditures included in the sample were charged to the wrong grant. Advertising costs charged to the grant were not necessary for the performance of the Federal award. Additionally, the Organization’s internal controls over tracking grant expenditures includes both tracking within the general ledger system and on manual spreadsheets, which are utilized to support grant drawdowns. Inconsistencies between the two tracking systems were identified through both a reconciliation of Federal awards received and expended within the general ledger system and sampling referenced above. Effect – The Organization charged unallowable advertising costs to the grant. Cause – The Organization’s accounts payable process did not identify the difference in allowability of costs when invoices included advertising services for multiple grants. The Organization’s internal control over compliance involves duplicative effort tracking grant expenditures and routine allocation of expenditures after-the-fact to correct the assignment of grant segments to expenses in the general ledger system. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions – Education regarding coding of invoices to grants and only picking up current balances due has been done to both grant project directors and accounts payable. Going forward, we will ensure no balances are duplicated and grant directors can ensure the balances charged to their grants as appropriate and approved. Recommendation – The Organization should implement a process of obtaining approval of the grant segment assignment upon receipt of each invoice by an individual with knowledge of compliance requirements and the HRSA-approved grant budget, but distinct from the requestor of the expense. With increased oversight of grant segment assignments at the time of recording grant expenditures, the Organization should eliminate manual tracking of grant expenditures via spreadsheet and reduce the risk of double-dipping due to prevalence of manual journal entries to assign grant segments to expenditures. Views of responsible officials and planned corrective actions –

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 U.S. Department of Treasury Missouri Primary Care Association Criteria or specific requirement – Procurement (2 CFR 200.319 and 2 CFR 200.320) Condition – The Organization’s internal controls over compliance were not sufficient to ensure the appropriate procurement method was utilized based on the value of the procurement transaction or to ensure procurement transactions were conducted in a manner that provided full and open competition. Cause – The Organization did not follow its policy when procuring services during the pre-construction phase of a project later funded by federal grants. Effect or potential effect – A contract for services was entered into during 2022 with estimated fees in excess of the threshold requiring a formal procurement method. The request for proposal did not allow for full and open competition as the Organization did not publicly request proposals or bids and only one proposal was obtained. Services purchased in 2024 under this contract may not have been obtained in the most effective manner. Questioned costs – Unknown Context – A sample of one procurement totaling $336,274 was tested out of a population of three procurements. The sample was not, and is not intended to be, statistically valid. The Organization’s procurement records were insufficient in accordance with the Organization’s procurement policy and Uniform Guidance. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should educate employees on its procurement policy, which is compliant with Uniform Guidance. The Organization should also implement additional internal controls, such as the creation of a standard form or template for purchase orders, contracts, requests for proposals/bids, cost/price analyses, bid evaluation, etc., to ensure compliance with its procurement policy and that procurement records sufficient to detail the history of each procurement transaction are maintained. Views of responsible officials and planned corrective actions – This error occurred during fiscal year 2022, when the architect for an upcoming project was chosen. We are in a very rural area, where architects are not easy to come by. For this project, we had decided to utilize a local firm we had a good track record with. We presented it to our board for approval, and it was approved by them at that time so we originally had thought we could justify with having them as a sole source vendor. At the time, the total amount of the project was unknown, and has even changed significantly since that date. However, come to find out, due to the size of the project it should have been bid out. We have revised our procurement policy since this date and have educated all staff on proper procurement procedures.