U.S. Department of Health and Human Services Federal Financial Assistance Listing Number 93.696, 1H79SM088927-01, September 29, 2024 and September 29, 2025 Certified Community Behavioral Health Clinic Expansion Grants Cash Management Significant Deficiency in Internal Control over Compliance Criteria The OMB Compliance Supplement requires that non-federal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Condition During our testing of reimbursement requests, there was no documentation available for the review and approval procedures performed. Cause The Organization did not have an adequate internal control policy to require the documentation of the reimbursement requests’ review and approval. Effect Inaccurate reimbursement requests may be prepared, which could lead to amounts received in error. Questioned Costs None. Context/Sampling There was a total of two reimbursement requests prepared for the year ended June 30, 2025 all of which were selected for testing. None of the reimbursement requests contained documentation of the request being reviewed or approved. Repeat Finding from Prior Year(s) Yes, prior year finding 2024-005 Recommendation We recommend the Organization enhance internal control policies to require documentation of the review and approval procedures performed in the preparation and review of reimbursement requests. Views of Responsible Individuals Management agrees with the finding.
U.S. Department of Health and Human Services Federal Financial Assistance Listing Number 93.696, 1H79SM088927-01, September 29, 2024 and September 29, 2025 Certified Community Behavioral Health Clinic Expansion Grants Reporting Significant Deficiency in Internal Control over Compliance Criteria The OMB Compliance Supplement requires that non-federal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Condition During our testing of reporting, there was no documentation available for the review and approval procedures performed for one of the reports tested. Cause The Organization did not have an adequate internal control policy to require the documentation of the reports’ review and approval. Effect Inaccurate reports may be prepared, which could lead to amounts reported in error. Questioned Costs None. Context/Sampling There was a total of two reports prepared for the year ended June 30, 2025 all of which were selected for testing. One of the reports did not contain documentation of the report being reviewed or approved. Repeat Finding from Prior Year(s) No Recommendation We recommend the Organization enhance internal control policies to require documentation of the review and approval procedures performed in the preparation and review of reports. Views of Responsible Individuals Management agrees with the finding.
U.S. Department of Health and Human Services Federal Financial Assistance Listing Number 93.696, 1H79SM088927-01, September 29, 2024 and September 29, 2025 Certified Community Behavioral Health Clinic Expansion Grants Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Material Weakness in Internal Control over Compliance and Noncompliance Criteria The OMB Compliance Supplement requires that non-federal entities receiving federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Condition During our testing, not all expenditures allocated to the federal program had documentation of review and approval. In addition, an expenditure was determined to be unallowed. Cause The Organization did not have an adequate internal control policy to ensure review and approval of expenditures and the allocation of expenditures to the federal program was documented and all expenditures were allowed. Effect The lack of adequate policies governing the recording of expenditures to the program increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs $73,600 Context/Sampling A nonstatistical sample of 60 direct expenditures and two indirect expenditures submitted for reimbursement were selected for testing. Of these 62, 54 did not show evidence of proper review and approval prior to being allocated to the federal program and one was determined to be unallowed. Repeat Finding from Prior Year(s) Yes, prior year finding 2024-006 Recommendation We recommend that the Organization enhance internal control policies to ensure all expenditures are reviewed and approved prior to payment to ensure that all payments are necessary for the program and correct. Views of Responsible Individuals Management agrees with the finding.
U.S. Department of Health and Human Services Federal Financial Assistance Listing Number 93.696, 1H79SM088927-01, September 29, 2024 and September 29, 2025 Certified Community Behavioral Health Clinic Expansion Grants Procurement and Suspension and Debarment Material Weakness in Internal Control over Compliance and Noncompliance Criteria The Uniform Guidance, Section 200.303 Internal Controls, requires the non‐federal entity must establish and maintain effective internal controls over federal awards that provide reasonable assurance that awards are being managed in compliance with federal statutes, regulations and the terms and conditions of the federal award. Condition The Organization entered into contracts with vendors for services without following their procurement policy. Cause There is a lack of controls over procurement, suspension and debarment as a whole. Effect Failure to follow a written procurement policy that was consistent with Federal, State, local, and tribal laws and regulations may result in disallowed costs. Questioned Costs $133,600 was paid during fiscal year 2025 to vendors without following the procurement policy. Context/Sampling EB reviewed the procurement, suspension and debarment policy. A nonstatistical sample of four vendors were selected for testing. Of these four, two did not follow appropriate procurement, suspension and debarment procedures. Repeat Finding from Prior Year(s) Yes, prior year finding 2024-007 Recommendation We recommend that management review and follow its policy prior to entering into any contracts with vendors. Views of Responsible Individuals Management agrees with the finding.