Finding Number 2024-043 Subject Heading (Financial) or AL no. and program name (Federal) ALN: 21.027 Federal Program name: Coronavirus State And Local Fiscal Recovery Funds (CSLFRF) Planned Corrective Action Office of Management Enterprise Services – Grant Management Office Response: The Oklahoma Office of Management and Enterprise Services (OMES) agrees that strong project planning and feasibility evaluations for large-scale capital projects are important processes for each individual agency to implement. OMES also recognizes that certain factors can impact the original evaluation, and if those factors occur, reevaluation of a project’s feasibility is a prudent measure to determine the future direction of a project. The Federal regulation 2 CFR § 200.317, directs that “a State must follow the same policies and procedures it uses for procurements from its non-Federal funds.” Oklahoma has laws in place for state agencies for the purchase of tangible and intangible property, which ensure obligations are properly encumbered by a contract or purchase order. Therefore, OMES agrees that in order to be in compliance with federal and state laws and regulations, each individual agency should have strong internal controls in place to ensure obligations of federal funds are properly encumbered before commitments are made. ODMHSAS Response to Finding No. 2024-043 ODMHSAS partially concurs with Finding No. 2024-043. ODMHSAS agrees that controls should be strengthened for large-scale federally funded capital projects and acknowledges the separate encumbrance issue identified in the finding. ODMHSAS does not concede that the full $6,218,295 questioned amount was wasted, unallowable, or subject to repayment based solely on the later cancellation of the original Donahue new-build project. ODMHSAS acknowledges that the original Donahue Behavioral Health Campus new-build project did not proceed to construction and that the Department later pursued a different facility solution through acquisition and renovation of an existing facility. The Donahue project, however, was an active, legislatively funded capital project intended to replace Griffin Memorial Hospital at the time the expenditures were incurred. Based on the available expenditure detail, the questioned-cost population includes architectural services, site or lease-related payments, consulting services, surveying or mapping services, and other planning and development costs associated with the project. ODMHSAS recognizes that the original project did not result in a completed capital asset. ODMHSAS also recognizes that federal allowability requires more than the existence of an approved project. Costs must be necessary, reasonable, allocable, and adequately documented. For that reason, ODMHSAS will conduct a reasonable transaction-level review using available records to determine what documentation exists for the expenditures identified in this finding, what work was performed, whether any deliverable or work product was received, whether the expenditure provided planning, feasibility, decision-making, or other project value, and whether further coordination with OMESGMO is needed regarding accounting treatment or other resolution. ODMHSAS further notes that the decision to discontinue the original Donahue new-build project should not, by itself, determine whether every planning or development cost incurred before cancellation was wasted or unallowable. ODMHSAS did not pay for a completed building at that stage of the project; it paid for planning, design, cost-estimating, site-evaluation, and feasibility-related services for an authorized replacement hospital project. The SLFRF capitalexpenditure framework recognizes that recipients may evaluate the need addressed, the appropriateness of a capital expenditure, and alternative capital approaches before determining the best path forward. Available information indicates the original concept contemplated moving both Griffin Memorial Hospital and CRC functions to the Donahue site, and the project scope, bed count, and estimated cost were later reevaluated as construction costs increased significantly, including post-COVID construction-cost escalation. Those services produced project information, design materials, cost information, and feasibility analysis that provided decision-making value, including information that helped ODMHSAS determine that the original newbuild approach was not financially feasible and that an alternative facility solution was necessary before substantially greater construction costs were incurred. ODMHSAS will therefore review the expenditures by category and transaction rather than treating the later cancellation of the project as dispositive of the allowability or value of each prior cost. ODMHSAS also notes the timing of the legislative and project changes. On October 5, 2022, the Legislature appropriated $87 million through HB 1013 for construction of a replacement facility for Griffin Memorial Hospital. During SFY 2024, ODMHSAS incurred planning, design, and initial development expenditures for the Donahue Behavioral Health Campus. The original new-build approach later became financially infeasible due to escalating construction costs and budget shortfalls, and by May 2025 ODMHSAS had moved away from the original construction plan and pursued acquisition and renovation of the former SSM Health facility as the successor facility solution. SB 1178 then reappropriated and redesignated $66.5 million of the original $87 million appropriation from construction of a replacement facility for Griffin Memorial Hospital to purchase and renovation of a replacement facility for Griffin Memorial Hospital, within the same thirty (30) mile geographic limitation. SB 1178 also recognized that the original appropriation could be reduced by prior expenditures, encumbrances, and transfers. ODMHSAS does not contend that SB 1178 alone resolves the allowability of prior costs, but it is relevant context showing that the remaining project funding was redirected by legislative action for the same public-health purpose of replacing Griffin Memorial Hospital. ODMHSAS further notes that the successor SSM acquisition and renovation project continued the same underlying public health purpose as the original Donahue project: replacing Griffin Memorial Hospital and expanding behavioral health treatment capacity. Available SSM transaction documents reflect that ODMHSAS pursued the purchase of the property at 2129 S.W. 59th Street for use in addressing the ongoing demand for mental health services, and related lease documentation reflects that ARPA-SLFRF funds used for the lease were designated for behavioral health services expansion. After the original Donahue new-build approach was no longer financially viable, ODMHSAS pursued the SSM acquisition and renovation approach as a feasible alternative to continue the Griffin replacement purpose. ODMHSAS will also review whether any amounts included in the federal questioned-cost population were recovered, refunded, offset, corrected, or otherwise resolved after the original expenditure. Separately, ODMHSAS has identified Donahue-related refund activity associated with private donations and grants, including an Oklahoma State University refund of $4,822,671.93, donor refunds totaling $1,820,000, and a remaining balance of $3,002,671.93 as of March 26, 2026. Based on current information, ODMHSAS understands this activity to relate to private donations and grants, not CSLFRF/ARPA funds. ODMHSAS will review the underlying accounting records to confirm the funding source, deposit, refund, and remaining balance treatment, and to ensure that this private donation and grant activity is treated separately from the federal questioned-cost population. ODMHSAS has also identified local contribution activity within the questioned-cost population that requires further review. Based on initial internal review, approximately $2.5 million of the questioned-cost population appears to relate to Oklahoma County and City of Oklahoma City contributions associated with the Donahue project, including $1.5 million from Oklahoma County and $1 million from the City of Oklahoma City. ODMHSAS understands that the Oklahoma County amount was repaid in December 2025 and that the City of Oklahoma City amount remains associated with the successor OKCBHC/SSM project or related project accounting. ODMHSAS will review the underlying accounting records, funding-source documentation, refund records, and project accounting treatment to determine whether these local contribution amounts should remain in the federal questioned-cost population, should be treated separately, or should otherwise affect the questioned-cost amount. ODMHSAS acknowledges the separate encumbrance issue related to claim 629685. Based on available records, the claim involved an obligation for services that was incurred before the applicable purchase order and encumbrance process was completed, requiring a subsequent ratification. The Department recognizes that obligations should not be incurred before a valid purchase order and encumbrance are in place. As reflected in the finding, the $50,000 claim was corrected by payment with state funds and was not questioned. ODMHSAS will address that issue through strengthened pre-obligation controls, procurement review, and targeted guidance or training for staff responsible for initiating purchases or contracts. Nothing in this response should be construed as an admission that the full questioned-cost amount is unallowable or subject to repayment. ODMHSAS will coordinate with OMESGMO as needed after review of the available records, including any refund, recovery, offset, correction, or other accounting issue relevant to the questioned-cost population. Corrective Action Planned ODMHSAS will take reasonable steps to strengthen controls over planning, documentation, procurement, and encumbrance review for significant federally funded capital projects. ODMHSAS will develop or update internal review procedures for significant federally funded capital-project expenditures. The procedures will address project scope, available funding, estimated project cost, material changes in feasibility, and approval authority before substantial planning, design, development, or construction-related costs are incurred. The review process will be scaled to the size, complexity, and funding source of the project. ODMHSAS will also strengthen documentation expectations for federally funded capital project invoices. For future expenditures, invoices or supporting materials should identify the services performed, billing period, project phase, and connection to the approved project scope. Where invoices contain only general descriptions, such as “progress billing” or “work completed,” ODMHSAS will seek additional support from the vendor, project manager, or available project file before approving the cost for federal reimbursement. ODMHSAS will require program or project-level confirmation that services were received and were related to the approved project before payment or reimbursement is processed. Finance and Procurement will review federally funded capital-project expenditures for appropriate coding, available support, and compliance with applicable funding and encumbrance requirements. ODMHSAS will conduct a risk-based review of the Donahue expenditures identified in Finding No. 2024-043 using available records. The review will focus on identifying the vendor, amount, funding source, available support, and whether any cost was refunded, recovered, offset, corrected, or requires additional accounting review or coordination with OMES-GMO. Because many of the underlying project decisions and records predate current leadership and staff, ODMHSAS will conduct this review based on the documentation reasonably available to the Department. As part of that review, ODMHSAS will review available accounting and reporting records for the Donahue and SSM projects to determine how ARPA-SLFRF funds associated with the replacement-facility work were obligated, reported, redirected, or applied to the successor Griffin replacement facility project, and whether that treatment affects the federal questioned-cost population. ODMHSAS will separately review the Donahue-related private donation and grant refund activity, including the OSU-OKC settlement documentation, to confirm the funding source, deposit, refund, and remaining balance treatment, and to ensure that non-federal donation and grant activity is not included in, or confused with, the federal questioned-cost population. ODMHSAS will also review the Oklahoma County and City of Oklahoma City contribution amounts identified within the questioned-cost population, including documentation of the reported Oklahoma County repayment and the accounting treatment of the City of Oklahoma City contribution, to determine whether those amounts should remain in the federal questioned-cost population, should be treated separately, or otherwise affect the questioned-cost amount. To address the encumbrance concern, ODMHSAS will implement or reinforce a pre-obligation verification process for future procurements. Staff responsible for initiating purchases, contracts, task orders, or service authorizations will be directed to confirm that a valid purchase order and encumbrance are in place before authorizing work. Any transaction requiring ratification will be reviewed to determine the cause and whether additional corrective action is needed. ODMHSAS will provide targeted written guidance and, as needed, training to appropriate staff regarding federal documentation requirements, invoice review, project-scope review, funding-source verification, and state encumbrance requirements. Anticipated Completion Date ODMHSAS anticipates completing updated procedures, review checklists, and targeted written guidance by June 30, 2027. Because the Donahue review requires analysis of historical project expenditures, related accounting and reporting records, multiple funding sources, and coordination with OMESGMO, ODMHSAS anticipates completing the risk-based transaction review and related followup by December 31, 2027. Responsible Contact Person OMES: Elizabeth Base 452: Chad Carden