Audit 365599

Finding 2024.002: Procurement, Suspension and Debarment - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.213 and §180.300, non-federal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Condition There was no evidence that the Center reviewed certain vendors for suspension and debarment in accordance with Uniform Guidance requirements. Cause The Center did not have adequate controls to illustrate review of vendors for any suspensions or debarment. Effect The Center may procure goods and services from vendors that have been suspended or debarred from doing business with the federal government. Questioned Costs None Context We selected a sample of five vendors for suspension and debarment testing relating to these major programs. For three vendors tested, management did not provide adequate supporting documentation to support that the vendors were not suspended or debarred. Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure vendors are being reviewed for suspension and debarment and there is evidence of a formal review being performed.

Finding 2024.003: Cash Management - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.305, federal payment, grantees and subgrantees that receive grant funds are responsible for maintaining controls regarding the management of federal program funds under the Uniform Guidance in 2 CFR 200.302 and 200.303. Condition The Center's drawdowns did not illustrate review and approval by management. Cause The Center did not have adequate controls to ensure drawdowns were properly approved and such approval is documented. Effect The condition may lead to inaccurate or improper drawdowns. Questioned Costs None Context We selected seven drawdowns for testing of cash management relating to these major programs. We noted there was no formal approval or evidence of review for these drawdowns Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure there is formal evidence of review being performed.

Finding 2024.002: Procurement, Suspension and Debarment - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.213 and §180.300, non-federal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Condition There was no evidence that the Center reviewed certain vendors for suspension and debarment in accordance with Uniform Guidance requirements. Cause The Center did not have adequate controls to illustrate review of vendors for any suspensions or debarment. Effect The Center may procure goods and services from vendors that have been suspended or debarred from doing business with the federal government. Questioned Costs None Context We selected a sample of five vendors for suspension and debarment testing relating to these major programs. For three vendors tested, management did not provide adequate supporting documentation to support that the vendors were not suspended or debarred. Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure vendors are being reviewed for suspension and debarment and there is evidence of a formal review being performed.

Finding 2024.003: Cash Management - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.305, federal payment, grantees and subgrantees that receive grant funds are responsible for maintaining controls regarding the management of federal program funds under the Uniform Guidance in 2 CFR 200.302 and 200.303. Condition The Center's drawdowns did not illustrate review and approval by management. Cause The Center did not have adequate controls to ensure drawdowns were properly approved and such approval is documented. Effect The condition may lead to inaccurate or improper drawdowns. Questioned Costs None Context We selected seven drawdowns for testing of cash management relating to these major programs. We noted there was no formal approval or evidence of review for these drawdowns Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure there is formal evidence of review being performed.

Finding 2024.002: Procurement, Suspension and Debarment - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.213 and §180.300, non-federal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Condition There was no evidence that the Center reviewed certain vendors for suspension and debarment in accordance with Uniform Guidance requirements. Cause The Center did not have adequate controls to illustrate review of vendors for any suspensions or debarment. Effect The Center may procure goods and services from vendors that have been suspended or debarred from doing business with the federal government. Questioned Costs None Context We selected a sample of five vendors for suspension and debarment testing relating to these major programs. For three vendors tested, management did not provide adequate supporting documentation to support that the vendors were not suspended or debarred. Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure vendors are being reviewed for suspension and debarment and there is evidence of a formal review being performed.

Finding 2024.003: Cash Management - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.305, federal payment, grantees and subgrantees that receive grant funds are responsible for maintaining controls regarding the management of federal program funds under the Uniform Guidance in 2 CFR 200.302 and 200.303. Condition The Center's drawdowns did not illustrate review and approval by management. Cause The Center did not have adequate controls to ensure drawdowns were properly approved and such approval is documented. Effect The condition may lead to inaccurate or improper drawdowns. Questioned Costs None Context We selected seven drawdowns for testing of cash management relating to these major programs. We noted there was no formal approval or evidence of review for these drawdowns Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure there is formal evidence of review being performed.

Finding 2024.002: Procurement, Suspension and Debarment - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.213 and §180.300, non-federal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Condition There was no evidence that the Center reviewed certain vendors for suspension and debarment in accordance with Uniform Guidance requirements. Cause The Center did not have adequate controls to illustrate review of vendors for any suspensions or debarment. Effect The Center may procure goods and services from vendors that have been suspended or debarred from doing business with the federal government. Questioned Costs None Context We selected a sample of five vendors for suspension and debarment testing relating to these major programs. For three vendors tested, management did not provide adequate supporting documentation to support that the vendors were not suspended or debarred. Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure vendors are being reviewed for suspension and debarment and there is evidence of a formal review being performed.

Finding 2024.003: Cash Management - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.305, federal payment, grantees and subgrantees that receive grant funds are responsible for maintaining controls regarding the management of federal program funds under the Uniform Guidance in 2 CFR 200.302 and 200.303. Condition The Center's drawdowns did not illustrate review and approval by management. Cause The Center did not have adequate controls to ensure drawdowns were properly approved and such approval is documented. Effect The condition may lead to inaccurate or improper drawdowns. Questioned Costs None Context We selected seven drawdowns for testing of cash management relating to these major programs. We noted there was no formal approval or evidence of review for these drawdowns Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure there is formal evidence of review being performed.

Finding 2024.002: Procurement, Suspension and Debarment - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.213 and §180.300, non-federal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Condition There was no evidence that the Center reviewed certain vendors for suspension and debarment in accordance with Uniform Guidance requirements. Cause The Center did not have adequate controls to illustrate review of vendors for any suspensions or debarment. Effect The Center may procure goods and services from vendors that have been suspended or debarred from doing business with the federal government. Questioned Costs None Context We selected a sample of five vendors for suspension and debarment testing relating to these major programs. For three vendors tested, management did not provide adequate supporting documentation to support that the vendors were not suspended or debarred. Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure vendors are being reviewed for suspension and debarment and there is evidence of a formal review being performed.

Finding 2024.003: Cash Management - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.305, federal payment, grantees and subgrantees that receive grant funds are responsible for maintaining controls regarding the management of federal program funds under the Uniform Guidance in 2 CFR 200.302 and 200.303. Condition The Center's drawdowns did not illustrate review and approval by management. Cause The Center did not have adequate controls to ensure drawdowns were properly approved and such approval is documented. Effect The condition may lead to inaccurate or improper drawdowns. Questioned Costs None Context We selected seven drawdowns for testing of cash management relating to these major programs. We noted there was no formal approval or evidence of review for these drawdowns Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure there is formal evidence of review being performed.

Finding 2024.002: Procurement, Suspension and Debarment - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.213 and §180.300, non-federal entities cannot enter into awards, subawards, or contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities. Condition There was no evidence that the Center reviewed certain vendors for suspension and debarment in accordance with Uniform Guidance requirements. Cause The Center did not have adequate controls to illustrate review of vendors for any suspensions or debarment. Effect The Center may procure goods and services from vendors that have been suspended or debarred from doing business with the federal government. Questioned Costs None Context We selected a sample of five vendors for suspension and debarment testing relating to these major programs. For three vendors tested, management did not provide adequate supporting documentation to support that the vendors were not suspended or debarred. Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure vendors are being reviewed for suspension and debarment and there is evidence of a formal review being performed.

Finding 2024.003: Cash Management - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Substance Abuse and Mental Health Services Projects of Regional and National Significance Certified Community Behavioral Health Clinic Expansion Grants Federal Assistance Listing Number: 93.243 and 93.696 Federal Award Identification Number and Year: H79SM087223 - 2024, H79SM086969 - 2024 Criteria In accordance with §200.305, federal payment, grantees and subgrantees that receive grant funds are responsible for maintaining controls regarding the management of federal program funds under the Uniform Guidance in 2 CFR 200.302 and 200.303. Condition The Center's drawdowns did not illustrate review and approval by management. Cause The Center did not have adequate controls to ensure drawdowns were properly approved and such approval is documented. Effect The condition may lead to inaccurate or improper drawdowns. Questioned Costs None Context We selected seven drawdowns for testing of cash management relating to these major programs. We noted there was no formal approval or evidence of review for these drawdowns Identification of Repeat Finding Not a repeat finding. Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Views of Responsible Officials and Planned Corrective Actions Management and the Board of Directors agree with the finding and will implement additional controls to ensure there is formal evidence of review being performed.