Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.
Finding 2024-001 Procurement
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title 2
U.S. Code of Federal Regulations (CFR) Part 200, paragraph 318 “General Procurement
Standards” states that the non-Federal entity must use its own documented procurement
procedures which reflect applicable State, local, and tribal laws and regulations, provided that the
procurements conform to applicable Federal law and the standards. Furthermore, paragraph 319
“Competition” states that all procurement transactions must be conducted in a manner providing
full and open competition consistent with these standards.
Condition: We noted that BCHC does not have a written procurement policy in accordance with 2
CFR 200. We also noted that although certain vendors were included in award proposals by
BCHC, full and open competition was not documented for certain purchases using Federal funds.
Cause: BCHC does not have a procurement policy in accordance with 2 CFR 200 and is therefore
not following the procedures required within 2 CFR 200.
Effect or Potential Effect: BCHC could incur disallowed costs for not properly procuring goods
and services.
Questioned Costs: $200,000
Context: BCHC is at risk of entering into contracts for goods or services under Federal awards
that were not adequately procured based on the regulations in the Uniform Guidance and the
awarding agency or pass-through entity could disallow the costs paid for the goods or services.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: We recommend that BCHC develop and implement a formal procurement
policy that complies with the Uniform Guidance (2 CFR 200.317–200.327), specifically addressing
requirements for full and open competition, documentation of procurement procedures, and
selection criteria for vendors. The policy should establish thresholds for the different procurement
methods (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and noncompetitive
proposals) and clearly outline the circumstances under which non-competitive
procurement is permissible. These exceptions include sole source availability, public exigency or
emergency, explicit authorization by the Federal awarding agency or pass-through entity, or
inadequate competition despite solicitation efforts should be defined in accordance with 2 CFR §
200.320(c). Additionally, the policy should require that all purchases using Federal funds are
supported by appropriate documentation of the procurement process and justification for the
selected method.
Finding 2024-002 Payroll
Information on the Federal Programs: 93.421
Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Per 2
CFR 200.430(i) of the Uniform Guidance, charges to Federal awards for salaries and wages must
be based on records that accurately reflect the work performed. These records must support the
distribution of employees’ salaries among specific activities or cost objectives as required.
Condition: During our review of payroll charges to Federal awards, we noted that BCHC did not
use timesheets from January 2024 to August 2024 and recorded salaries based on budgeted
allocations. In August 2024, timesheets were implemented but we noted that the time recorded in
the general ledger did not coincide with the allocation on the actual timesheets.
Cause: BCHC relied on predetermined budget estimates for payroll allocation rather than using
timesheets that reflected actual hours worked.
Effect or Potential Effect: There is a risk that payroll costs charged to Federal programs may not
accurately represent the true level of effort, potentially resulting in unallowable costs being charged
to Federal awards.
Questioned Costs: Indeterminate-The questioned costs relate to salary and wage expenditures
charged to Federal programs without the required time and effort documentation in accordance
with 2 CFR §200.430. Specifically, employees whose compensation was allocated to Federal
awards did not maintain timesheets or equivalent records reflecting actual time worked on specific
Federal activities.
Due to the absence of these records, we were unable to determine the portion of personnel costs
that may be unallowable under Uniform Guidance. Accordingly, the questioned costs are
considered indeterminate.
Context: We sampled 40 payroll transactions. All transactions were based on budgeted amounts.
This issue was observed across all departments receiving Federal funds.
Identification as a Repeat Finding, if Applicable: Not applicable
Recommendation: While BCHC now maintains timesheets, we recommend ensuring that payroll
costs charged to Federal awards are based on the actual time recorded, rather than budgeted
estimates. The timesheet data should be used to support allocations in accordance with Uniform
Guidance, and adjustments should be made as needed to reflect the actual effort expended on
Federal programs.