Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) and /or I-9 forms are not maintained for certain employees as required by federal cost principles.
Cause: The Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain complete I-9 forms for all employees.
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for 21 employees were not maintained, and 4 employees had missing or incomplete I-9 forms. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: The Organization should evaluate and revise its processes and procedures to ensure that it maintains documentation of personnel time and efforts in accordance with federal cost principles and that I-9 forms are maintained for all employees. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-005 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527 & 93.224
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the Organization establish policies and procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-006-Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No.- 93.224 and 93.527
Criteria: Organizations that receive federal awards in excess of $750,000 are required to submit an annual Federal Data Collection Form, including audited financial statements, no later than nine months after their fiscal year-end to the Federal Audit Clearinghouse.
Condition: The Federal Data Collection Form and audit report for the year ended November 30, 2023, were not submitted to the Federal Audit Clearinghouse until February 5, 2025, which was beyond the filing period of August 31, 2024.
Cause: The late issuance of the Organization’s audited financial statements for the year ended November 30, 2023 was a result of an audit firm withdrawing from the audit. The Organization was unable to engage an audit firm in a timeframe that would allow for the audit report to be filed in a timely manner with the Federal Audit Clearinghouse.
Effect: The Organization is not in compliance with federal filing requirements, which could impact availability of federal funds.
Questioned Costs: None reported
Context/Sampling: None
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that the annual audit and Federal Data Collection Form be completed and filed in a timely manner.
Views of Responsible Officials: Management concurs. The Organization has made a change in service providers for the completion of future audits.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: August 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025
Finding: 2024-007 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 2 CFR 200.305(b)(1)
Condition: Due to staff turnover, the Organization was unable to immediately provide proper documentation to support the fact that qualifying expenditures were made prior to making certain drawdowns of federal funds. No grant draws exceeded the cash needs for grant-related expenditures. However, failure to reconcile expenditures to federal grant draws, and failure to maintain such documentation, could result in advance draws.
Cause: The Organization did not maintain proper documentation of expenditures to support the drawdowns made,
Effect: Without proper controls over the reconciliation of expenditures to federal grant draws, drawdowns may occur for the incorrect amount, for the wrong period, and for costs that may not have been incurred.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented.
Views of Responsible Officials: The Organization understands the requirements to document expenditures prior to drawing down federal funds. Procedures will be established to ensure that federal grant expenditures are documented so that advance draws of federal funds do not occur.
Contact Person: Suzanne Freeman, CEO
Anticipated Date of Completion: October 31, 2025