2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-001 – Procurement and Suspension and Debarment
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318
through 200.326. They must use their own documented procurement procedures, which reflect applicable
state and local laws and regulations, provided that the procurements conform to applicable federal statutes
and the procurement requirements identified in 2 CFR Part 200.
Condition: The Organization's procurement policies were not complete and the Organization did not follow
the federal procurement standards which provides specific guidance including process and documentation
requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326.
Cause: The Organization’s procurement policies do not include the federal procurement requirements
noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the
required procurement documentation, provide for full and open competition, or provide support for limitation
of such competition.
Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects
funded by federal sources. The Organization may have to pay back funds received for a project where
federal funds were used for the procurement of products or services, but the required federal process was
not met.
Recommendation: The Organization should update their procurement policy to include all requirements as
noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required
processes.
View of Responsible Officials: Management agrees with the finding and plans to update their procurement
policy.
Repeat Finding - 2022-001
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-002 – Financial Reporting
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328.
The Organization did not trace the amounts reported to accounting records that support the audited financial
statements and the schedule of expenditures of federal awards to verify accuracy and completeness.
Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior
to submission.
Cause: The Organization does not have an adequate level of review in place to properly monitor the
amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the
actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR
section 200.328 of tracing amounts to records and verifying for accuracy and completeness.
Effect: The Organization may not be eligible for future funding or might have to pay back federal funds
received for not appropriately identifying and reporting their actual expenses.
Questioned Costs: No costs were questioned as a result of this finding.
Recommendation: The Organization should implement procedures for verifying accuracy and
completeness prior to submission.
View of Responsible Officials: Management agrees with the finding and plans to implement procedures for
verifying accuracy and completeness prior to submission.
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003
2023-003 – Cash Management
Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance
Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network
Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all
grant numbers.
Criteria: Management is responsible for establishing and maintaining effective internal control over the
advance payment requests related to federal awards. This includes review and approval for the advance
draw from an individual other than the one requesting the draw, as well as support demonstrating that
existing grant funds received were expended prior to additional funds being requested.
Condition: The Organization was unable to provide documentation to support the advanced draw
calculation estimate or its approval by someone other than the individual who requested the draw for eleven
of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully
expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested.
Cause: The Organization does not have a consistent process in place to estimate the amount of advance
draws for a 30-day period of needed funding, nor do they have a consistent process in place for the
documentation of the review/approval of the advance draw by someone other than the individual who
requests the funds.
Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or
staff could request funds without the proper approval.
Questioned Costs: $460,000.
Recommendation: The Organization should develop a clearly documented process and method to
determine the amount of advance draw not to exceed a 30-day need. This process should include
appropriate review, approval and documentation of the advance draw prior to requesting the funds.
View of Responsible Officials: Management agrees with the finding and will develop a process and method
to determine the appropriate calculation for the advance draw process including the proper review and
approvals.
Repeat Finding - 2022-003