Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Criteria: The Organization is required to submit federal financial reports (SF-425) and the annual
Uniform Data System (UDS) report in accordance with established requirements and deadlines.
These reports are to be prepared using accurate financial data. Condition: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report
for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs
selected for testing on the UDS report, four exceptions were noted. The Organization did not
maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table
8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be
calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Additionally, potential errors were made on the annual UDS report.
Questioned costs: n/a
Context: Three SF-425 reports and the annual UDS report submitted during the year were
selected for testing.
Repeat Finding: Yes, 2023-002
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting. Additionally, the
Organization should revise policies and procedures over reporting to ensure reports are
prepared using accurate information and documentation is maintained.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant-related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Criteria: The Organization is required to submit federal financial reports (SF-425) and the annual
Uniform Data System (UDS) report in accordance with established requirements and deadlines.
These reports are to be prepared using accurate financial data. Condition: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report
for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs
selected for testing on the UDS report, four exceptions were noted. The Organization did not
maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table
8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be
calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Additionally, potential errors were made on the annual UDS report.
Questioned costs: n/a
Context: Three SF-425 reports and the annual UDS report submitted during the year were
selected for testing.
Repeat Finding: Yes, 2023-002
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting. Additionally, the
Organization should revise policies and procedures over reporting to ensure reports are
prepared using accurate information and documentation is maintained.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant-related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Criteria: The Organization is required to submit federal financial reports (SF-425) and the annual
Uniform Data System (UDS) report in accordance with established requirements and deadlines.
These reports are to be prepared using accurate financial data. Condition: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report
for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs
selected for testing on the UDS report, four exceptions were noted. The Organization did not
maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table
8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be
calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Additionally, potential errors were made on the annual UDS report.
Questioned costs: n/a
Context: Three SF-425 reports and the annual UDS report submitted during the year were
selected for testing.
Repeat Finding: Yes, 2023-002
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting. Additionally, the
Organization should revise policies and procedures over reporting to ensure reports are
prepared using accurate information and documentation is maintained.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant-related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Criteria: The Organization is required to submit federal financial reports (SF-425) and the annual
Uniform Data System (UDS) report in accordance with established requirements and deadlines.
These reports are to be prepared using accurate financial data. Condition: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report
for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs
selected for testing on the UDS report, four exceptions were noted. The Organization did not
maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table
8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be
calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Additionally, potential errors were made on the annual UDS report.
Questioned costs: n/a
Context: Three SF-425 reports and the annual UDS report submitted during the year were
selected for testing.
Repeat Finding: Yes, 2023-002
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting. Additionally, the
Organization should revise policies and procedures over reporting to ensure reports are
prepared using accurate information and documentation is maintained.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant-related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Criteria: The Organization is required to submit federal financial reports (SF-425) and the annual
Uniform Data System (UDS) report in accordance with established requirements and deadlines.
These reports are to be prepared using accurate financial data. Condition: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report
for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs
selected for testing on the UDS report, four exceptions were noted. The Organization did not
maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table
8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be
calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Additionally, potential errors were made on the annual UDS report.
Questioned costs: n/a
Context: Three SF-425 reports and the annual UDS report submitted during the year were
selected for testing.
Repeat Finding: Yes, 2023-002
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting. Additionally, the
Organization should revise policies and procedures over reporting to ensure reports are
prepared using accurate information and documentation is maintained.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant-related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Criteria: The Organization is required to submit federal financial reports (SF-425) and the annual
Uniform Data System (UDS) report in accordance with established requirements and deadlines.
These reports are to be prepared using accurate financial data. Condition: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report
for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs
selected for testing on the UDS report, four exceptions were noted. The Organization did not
maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table
8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be
calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns.
Additionally, potential errors were made on the annual UDS report.
Questioned costs: n/a
Context: Three SF-425 reports and the annual UDS report submitted during the year were
selected for testing.
Repeat Finding: Yes, 2023-002
Recommendation: The Organization should review and evaluate grant reporting deadlines for
their federal awards and update internal control procedures for reporting. Additionally, the
Organization should revise policies and procedures over reporting to ensure reports are
prepared using accurate information and documentation is maintained.
Views of Responsible Officials: Management agrees with this finding. Management has
contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of
grant-related expenditures. Also, the Organization is in the process of creating the
administrative infrastructure which includes new staff, new workflow and processes that are
designed to report grant activity monthly which includes the timely submission of all grant
related reports.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: The Organization is required to create a written procurement, suspension and
debarment policy that complies with applicable federal requirements as indicated in 2 CFR
200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support
quotes, estimates, or closed bids was not maintained prior to entering into contracts.
Additionally, documentation was not maintained to support that the vendors were not
suspended or debarred.
Cause: The Organization has designed internal controls over these areas; however, the controls
did not operate as designed.
Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension
and debarment policy.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation that management
obtained price or rate quotes for purchases above the micro-purchase threshold. In addition,
the Health Center did not maintain documentation to support that the vendors were not
suspended or debarred, however subsequent testing verified that none of the vendors selected
for review were suspended or debarred.
Repeat Finding: Yes, 2023-003
Recommendation: The Organization should review and update the procurement and suspension
and debarment policies. Additionally, the Organization should provide training to staff on
transactions that are covered by the procurement, suspension and debarment policies.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future procurement, suspension and debarment transactions are identified and
documentation is maintained to support the evaluation.
Health Center Program Cluster
AL No. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. H80CS00438, H8FCS40427, H8GCS47600
Healthy Start Initiative
AL No. 93.926
Us. Department of Health and Human Services
Award No. H49MC00156
Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect
the work performed and supported by a system of internal control that provides reasonable
assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll
costs between programs, however, no time and effort certification or equivalent documentation
was updated to reflect the changes. Additionally, the transfer of payroll costs between grants
was not properly reflected within the accounting system records by grant. These transfers
between grants were completed after the end of the fiscal year.
Cause: During the year the Organization had new grants, but the payroll system was not
updated to reflect the changes.
Effect: Allocation of payroll costs to the federal award program may be inaccurate or not
properly documented.
Questioned costs: n/a
Context: The Organization did not maintain supporting documentation for payroll costs that
were reallocated to a new grant. These costs were reallocated from the Health Center Program
and from the Healthy Start Initiative funding to the new award.
Repeat Finding: No
Recommendation: The Organization should review and update the policies and procedures
regarding payroll costs. Additionally, the Organization should provide training to staff on grant
tracking and documentation.
Views of Responsible Officials: Management agrees with this finding. Staff will be trained to
ensure future changes in payroll costs are updated timely within the system and documentation
maintained.