Audit 404207

Material Weakness Finding No. 2024-002: Subrecipient Monitoring U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. U.S. Department of Health and Human Services Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. Criteria Pursuant to Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), “a non-Federal entity may concurrently receive Federal awards as a recipient, subrecipient, and a contractor, depending on the substance of its agreements with the Federal awarding agencies and pass-through entities. Therefore, a pass-through entity must make case-by-case determinations whether each agreement it makes for the disbursement of Federal program funds casts the party receiving the funds in the role of a subrecipient or a contractor.” Condition We noted that the Organization did not make case-by-case determinations of each agreement with parties to which the Organization passed through Federal program funds to determine whether they were deemed to be either subrecipients or contractors. Cause Management had not updated its policies and procedures to incorporate the relevant Uniform Guidance subrecipient monitoring and management policies. Effect The lack of subrecipient monitoring and management policies of the Uniform Guidance could result in noncompliance by the Organization with the stipulated requirements for pass-through entities, as well as noncompliance of subrecipient requirements by the entities receiving the pass-through funds from the Organization. Identification of Repeat Finding This finding was reported as a federal award finding in the immediate previous audit as Finding No. 2023-002. Recommendation We recommend that the Organization incorporate and adhere to the subrecipient monitoring and management provisions of 2 CFR §200.331 and 2 CFR §200.332 of the Uniform Guidance to their policies and procedures manual to ensure compliance with Federal standards.

Material Weakness Finding No. 2024-003: Procurement Policies U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. U.S. Department of Health and Human Services Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. Criteria The Uniform Guidance 2 CFR §200.320 sets forth the methods of procurement to be followed in the acquisition of property or services required under a Federal award or subaward, which includes formal purchase methods such as proposal or bids when the value of the property or services under a Federal financial assistance award exceeds a certain threshold, as defined. Furthermore, 2 CFR §200.320(c) provides specific circumstances in which noncompetitive procurement can be used. Condition During our audit, we noted that the Organization entered into contracts with entities which were subject to a formal purchase method, for which competitive processes for selection were not performed, nor was documentation of the specific criteria of 2 CFR §200.320(c) met to support noncompetitive procurements maintained. Cause Management had not updated its policies and procedures to incorporate certain pertinent sections of the procurement standards of the Uniform Guidance. Effect The lack of procurement standards in accordance with the Uniform Guidance may result in allowable cost issues. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediately previous audit as Finding No. 2023-003. Recommendation We recommend that the Organization incorporate and adhere to the procurement standards of the Uniform Guidance to its policies and procedures manual to ensure compliance with Federal standards, including 2 CFR §200.318(h) which stipulates that sufficient detail of the history of the procurement must be maintained, including the selection of the contractor.

Significant Deficiency Finding No. 2024-004: Reporting U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. U.S. Department of Health and Human Services Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. Criteria A non-Federal entity that expends $750,000 or more in Federal awards during the year must have a single audit conducted in accordance with 2 CFR §200.514. Pursuant to 2 CFR §200.512, the audit must be completed and Form SF-SAC: Data Collection Form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors’ report(s), or nine months after year end of the audit period. Condition Due to the unexpected resignation of its independent auditor, we noted that the Organization has not submitted the single audit reports required by the Uniform Guidance, including the Data Collection Form to the Federal Audit Clearinghouse for the year ended June 30, 2024, within the stipulated nine months after the end of the audit period. Cause The Organization has not adhered to established Uniform Guidance terms and conditions regarding the submission dates of the single audit reports and Data Collection Form for the year ended June 30, 2024. Effect The Organization is not in compliance with the Uniform Guidance terms and conditions regarding the submission dates of the single audit report and Data Collection Form for the year ended June 30, 2024. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediately previous audit as Finding No. 2023-004. Recommendation We recommend that the Organization incorporate internal controls and comply with the Uniform Guidance with respect to the submission deadline of single audit reports and the Data Collection Form.

Material Weakness Finding No. 2024-005: Document Retention U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. U.S. Department of Health and Human Services Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. Criteria Pursuant to Title 2, Subtitle A Chapter II, Part 200, of the Uniform Guidance, §200.334, “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…” Condition We noted that the Organization did not consistently retain documentation substantiating contractor performance of services was in accordance with the terms and conditions of the contract. Cause The Organization’s policies and procedures do not include specific requirements to ensure that pertinent supporting documents are obtained and retained to evidence contractor performance of services pursuant to Federal requirements. Effect The lack of supporting documents for contractor expenditures as stipulated by Uniform Guidance could result in noncompliance of Federal record retention polices by the Organization. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediately previous audit as Finding No. 2023-005. Recommendation We recommend that the Organization incorporate and adhere to policies and procedures to ensure the maintenance of adequate documentation to support contractor performance of services pursuant to contract terms.

Material Weakness Finding No. 2024-006: Cash Management U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. U.S. Department of Health and Human Services Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. Criteria Pursuant to 2 CFR §200.305, the payment methods for Federal payments to recipients must minimize the time elapsing between the transfer of funds from the Federal agency to the recipient and the disbursement of funds by the recipient. Condition We noted that the Organization’s director of administrative operations has implemented a methodology designed to minimize the time that advance payment requests are expended; however there are no internal controls in place over this process. Cause The Organization’s policies and procedures do not require an internal review of the payment requests and the subsequent disbursements of the Federal funds to ensure compliance with 2 CFR §200.305. Effect The lack of internal controls could result in noncompliance with 2 CFR §200.305. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediately previous audit as Finding No. 2023-006. Recommendation We recommend that the Organization incorporate internal controls over cash management to ensure compliance with 2 CFR §200.305.