Finding No.: 2019-007 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 5U79SM062447-04 Area: Procurement and Suspension and Debarment Questioned Costs: $23,500 Criteria: Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. CHCC’s procurement regulations, pursuant to the Commonwealth law, state the following: • All procurement records shall be retained by the CHCC Procurement and Supply (P&S) Director for a period of seven (7) years after completion of construction, or full delivery of the goods or services under the contract. • Competitive Sealed Bidding Because of the unique nature and varied needs of all parts of the institution, the CEO and the CHCC Director of P&S shall make a determination as to the best way to publicize the Invitation to Bid (ITB). Every procurement in excess of $10,000 shall be publicized in one or more of the following ways: (a) in a newspaper of general circulation; (b) in a newspaper of local circulation in the area pertinent to the procurement; (c) in industry media; (d) through electronic mailing lists, (e) through the internet, agency web site, or other publicly accessible electronic media, (f) through electronic mailing lists, or (g) in a government publication designed for giving public notice • Competitive Sealed Proposal Adequate public notice of the request for proposals shall be given in the same manner as provided for in competitive sealed bids. Finding No.: 2019-007, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 5U79SM062447-04 Area: Procurement and Suspension and Debarment Questioned Costs: $23,500 Criteria, continued: • Small Purchases Bidding is not required but is encouraged for procurement over $5,000 and under $25,000, or $50,000 if it is medical equipment, supplies, or devices. The CEO, the official with expenditure authority, must obtain price quotations from at least three vendors and base the selection on competitive price and quality for procurement valued at $5,000 to $25,000 or $50,000 for medical equipment, supplies, or devices. Any price quotations obtained must be written, documented, and submitted to the CHCC P&S Director for approval. Condition: Of thirty-nine procurement samples tested, aggregating $56,383 of a total population of $220,635, the following deficiencies were noted: 1. For four (or 10%), the Invitation to Bid (ITB) or the Request For Proposal (RFP) publication notices and evaluation forms were not provided. Finding No.: 2019-007, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 5U79SM062447-04 Area: Procurement and Suspension and Debarment Questioned Costs: $23,500 Condition, continued: 2. For seven (or 18%), the purchase requisitions and/or contracts were not provided. No questioned costs are presented as amounts are questioned at Condition 3. 3. For eight (or 21%), approval by the Expenditure Authority and the P&S Director were not evident. Finding No.: 2019-007, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 5U79SM062447-04 Area: Procurement and Suspension and Debarment Questioned Costs: $23,500 Condition, continued: 4. For one (or 3%) small purchase, no evidence of effort to obtain three quotations. Cause: CHCC did not enforce compliance with established procurement policies and procedures over procurement. Effect: CHCC is in noncompliance with applicable procurement regulations and questioned costs of $23,500 result as the projected questioned costs exceed the $25,000 threshold. Identification as a Repeat Finding: Finding No. 2018-013. Recommendation: The responsible personnel should monitor and enforce compliance with applicable procurement requirements, including the review of procurement files for completeness as to written rationale for any deviation from applicable procurement requirements. Finding No.: 2019-007, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 5U79SM062447-04 Area: Procurement and Suspension and Debarment Questioned Costs: $23,500 Views of Responsible Officials: CHCC’s Corrective Action Plan provides a detailed rationale for disagreement with the finding described in Conditions 1 to 4. Auditor Response: Condition 1 - ITB and RFP publication notices were not provided. Condition 2 - Purchase requisitions and/or contracts were not provided. Condition 3 - Documentations evidencing approval by the Expenditure Authority and the P&S Director were not provided. Condition 4 - CHCC Corrective Action Plan stated no solicitation was obtained. In addition, documentations substantiating that the vehicle rental agreement was competitively procured during the initial year of the rental were not provided. Further, in accordance with 45 CFR Part 75.361 Retention requirements for records, financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award, must be retained for a period of three years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the HHS awarding agency or pass-through entity in the case of a subrecipient. In addition, initial draft reports were provided to CHCC on 09/06/24 and 09/24/24. It was also agreed during the 09/06/24 and 10/04/24 meetings for CHCC to provide corresponding underlying accounting records to resolve the finding; however, no documentations were provided within the agreed timeline. Accordingly, finding is sustained.
Finding No.: 2019-011 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Award Number: 5U79SP020710-04 and 5H795M062879-02 Area: Procurement and Suspension and Debarment Questioned Costs: $183,926 Criteria: Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. CHCC’s procurement regulations, pursuant to the Commonwealth law, state the following: • All procurement records shall be retained by the CHCC Procurement and Supply (P&S) Director for a period of seven (7) years after completion of construction, or full delivery of the goods or services under the contract. • Competitive Sealed Bidding Because of the unique nature and varied needs of all parts of the institution, the CEO and the CHCC Director of P&S shall make a determination as to the best way to publicize the Invitation to Bid (ITB). Every procurement in excess of $10,000 shall be publicized in one or more of the following ways: (a) in a newspaper of general circulation; (b) in a newspaper of local circulation in the area pertinent to the procurement; (c) in industry media; (d) through electronic mailing lists, (e) through the internet, agency web site, or other publicly accessible electronic media, (f) through electronic mailing lists, or (g) in a government publication designed for giving public notice • Competitive Sealed Proposal Adequate public notice of the request for proposals shall be given in the same manner as provided for in competitive sealed bids. Finding No.: 2019-011, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Award Number: 5U79SP020710-04 and 5H795M062879-02 Area: Procurement and Suspension and Debarment Questioned Costs: $183,926 Criteria, continued: • Small Purchases Bidding is not required but is encouraged for procurement over $5,000 and under $25,000, or $50,000 if it is medical equipment, supplies, or devices. The CEO, the official with expenditure authority, must obtain price quotations from at least three vendors and base the selection on competitive price and quality for procurement valued at $5,000 to $25,000 or $50,000 for medical equipment, supplies, or devices. Any price quotations obtained must be written, documented, and submitted to the CHCC P&S Director for approval. • Sole Source Procurement A written justification for sole source procurement shall be prepared by the CEO, the official with expenditure authority, and shall contain the specific unique capabilities required; the specific unique capabilities of the contractor; the efforts made to obtain competition; and the specific considerations given to alternative sources and specific reasons why alternative sources were not selected. Condition: Of thirty-seven procurement samples tested, aggregating $232,278 of a total population of $1,068,186, the following deficiencies were noted: 1. For five (or 14%), procurement files were not provided. No questioned costs is presented for Document Number 249681 as the amount is questioned at Condition 2. Finding No.: 2019-011, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Award Number: 5U79SP020710-04 and 5H795M062879-02 Area: Procurement and Suspension and Debarment Questioned Costs: $183,926 Condition, continued: 2. For four (or 11%), approval by the Expenditure Authority and the P&S Director were not evident. 3. For four (or 11%), purchase requisitions and/or contracts were not provided. No questioned costs are presented as amounts are questioned at Condition 2. 4. For four (or 11%), either the Invitation to Bid (ITB) or Request for Proposal (RFP) publication notices and evaluations forms were not provided. Finding No.: 2019-011, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Award Number: 5U79SP020710-04 and 5H795M062879-02 Area: Procurement and Suspension and Debarment Questioned Costs: $183,926 Condition, continued: 5. For one (or 3%), there was no written justification by the Expenditure Authority for the sole source procurement method used for Document No. 1427946 (Business Unit H8243A), dated 11/30/18 amounting to $36,500. No questioned costs are presented as the amount is questioned at Finding No. 2019-010, Condition 2. 6. For three (or 8%) small purchase, no evidence of effort to obtain three quotations. No questioned costs are presented as the amount is questioned at Condition 2 for Document Number 1443186 and at Finding No. 2019-008, Condition 1 for Document Numbers 1456156 and 1456160. 7. For one (or 3%), the written justification by the Official Expenditure Authority of the sole source procurement method used was not provided. No questioned costs are presented as the amount is questioned at Finding No. 2019-010, Condition 2. Cause: CHCC did not enforce compliance with established procurement policies and procedures over procurement. Finding No.: 2019-011, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Award Number: 5U79SP020710-04 and 5H795M062879-02 Area: Procurement and Suspension and Debarment Questioned Costs: $183,926 Effect: CHCC is in noncompliance with applicable procurement regulations, and questioned costs of $183,926 exist. Identification as a Repeat Finding: Finding No. 2018-017. Recommendation: The responsible personnel should monitor and enforce compliance with applicable procurement requirements, including the review of procurement files for completeness as to written rationales for any deviations from applicable procurement requirements. Views of Responsible Officials: CHCC’s Corrective Action Plan states agreement with the findings described for Conditions 1 to 7; however, disagrees with the questioned costs. Auditor Response: Conditions 1 to 7 - Questioned costs are warranted given transactions tested were not supported by adequate documentations. In addition, initial draft reports were provided to CHCC on 09/06/24 and 09/24/24. It was also agreed during the 09/06/24 and 10/04/24 meetings for CHCC to provide corresponding underlying accounting records to resolve the finding; however, no documentations were provided within the agreed timeline. Accordingly, finding is sustained.
Finding No.: 2019-016 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Criteria: Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. CHCC’s procurement regulations, pursuant to the Commonwealth law, state the following: • All procurement records shall be retained by the CHCC Procurement and Supply (P&S) Director for a period of seven (7) years after completion of construction, or full delivery of the goods or services under the contract. • Competitive Sealed Bidding Because of the unique nature and varied needs of all parts of the institution, the CEO and the CHCC Director of P&S shall make a determination as to the best way to publicize the Invitation to Bid (ITB). Every procurement in excess of $10,000 shall be publicized in one or more of the following ways: a. in a newspaper of general circulation; b. in a newspaper of local circulation in the area pertinent to the procurement; c. in industry media; d. through electronic mailing lists, e. through the internet, agency web site, or other publicly accessible electronic media, f. through electronic mailing lists, or g. in a government publication designed for giving public notice • Competitive Sealed Proposal Adequate public notice of the request for proposals shall be given in the same manner as provided for in competitive sealed bids. • Small Purchases Bidding is not required but is encouraged for procurement over $5,000 and under $25,000, or $50,000 if it is medical equipment, supplies, or devices. The CEO, the official with expenditure authority, must obtain price quotations from at least three vendors and base the selection on competitive price and quality for procurement valued at $5,000 to $25,000 or $50,000 for medical equipment, supplies, or devices. Any price quotations obtained must be written, documented, and submitted to the CHCC P&S Director for approval. Finding No.: 2019-016, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Criteria, Continued: • Sole Source Procurement A written justification for sole source procurement shall be prepared by the CEO, the official with expenditure authority, and shall contain the specific unique capabilities required; the specific unique capabilities of the contractor; the efforts made to obtain competition; and the specific considerations given to alternative sources and specific reasons why alternative sources were not selected. Condition: Of thirty-seven nonpayroll expenditures tested, aggregating $75,546 of a total population of $212,059, the following deficiencies were noted: 1. For five (or 14%), written justifications by the Official Expenditure Authority for the sole source procurement method used were not provided. 2. For twelve (or 32%), the Invitation to Bid or Request for Proposal publications notices were not provided. Finding No.: 2019-016, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Condition, continued: 3. For nine (or 24%), purchase requisitions and/or contracts were not provided. No questioned costs are presented as amounts are questioned at Condition 4. Finding No.: 2019-016, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Condition, continued: 4. For nine (or 24%), approval by the Expenditure Authority and the P&S Director were not evident. 5. For three (or 8%), either the purchase order was not provided or was not signed by the P&S Director. No questioned costs are presented as amounts are questioned at Condition 4. 6. For one (or 3%) small purchase, no evidence of effort to obtain three quotations. No questioned costs are presented as the amount is questioned at Condition 4. Finding No.: 2019-016, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Cause: CHCC did not enforce compliance with established policies and procedures over procurement. Effect: CHCC is in noncompliance with applicable procurement regulations and questioned costs of $60,104 result. Identification as a Repeat Finding: Finding No. 2018-025. Recommendation: The responsible personnel should monitor and enforce compliance with applicable procurement requirements, including the review of procurement files for completeness as to written rationale for any deviation from applicable procurement requirements. Views of Responsible Officials: CHCC’s Corrective Action Plan states agreement with the finding described in Conditions 1 to 6; however, disagrees with the questioned costs. Auditor Response: Conditions 1 to 6 - Questioned Costs are warranted given transactions tested were not supported by adequate documentations. Finding No.: 2019-016, continued Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Auditor Response, continued: In addition, initial draft reports were provided to CHCC on 09/06/24 and 09/24/24. It was also agreed during the 09/06/24 and 10/04/24 meetings for CHCC to provide corresponding underlying accounting records to resolve the finding; however, no documentations were provided within the agreed timeline. Accordingly, finding is sustained.
Finding 2018 - 001 Procurement, Suspension & Debarment (I) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Non-federal entities must follow the procurement standards set out at 2 CFR Sections 200.318 through 200.326. They must use their own documented procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statues and the procurement requirements identified in 2 CFR Part 200 as described above. Finding/Condition: The procurement policies and procedures were found lacking as to the bidding and retaining process. We could not locate certain files indicating that the procurement requirements had been followed. In addition, we could not locate certain files indicating the debarment procedures had been properly followed per the requirements. Cause: Management lack of time to establishing a policy and procedure regarding this requirement. Effect: The lack of policies and procedures in this area may cause the Clinic to be out of compliance with this procurement, suspension and debarment requirement. A lack of competitive bidding may overstate allowable costs and a lack of debarment procedures may allow debarred vendors in providing material, supplies and services. Questioned Cost: None Recommendation: The Clinic should establish sound policies and procedures which conform to federal requirements for procurement, suspension and debarment. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Finding 2018-002 – Lack of Policies/Procedures & Documentation Related to Procurement/Suspension and Debarment (Material Weakness in Internal Controls over Compliance – Federal Program CFDA 10.766/10.780 Community Facilities Loans and Grants Cluster) Criteria: 2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, £200.318 requires that the auditee must have and use documented procurement procedures for the purchase/acquisition of any property or services under a Federal award. These must include written standards of conduct covering conflicts of interest, consideration of the most economical purchase, rationale for the method of procurement, selection of contractors including whether they have been barred from doing business with the federal government, and the basis for the contract price. Also, £200.319 requires all procurement transactions be conducted in a manner that provides full and open competition, and develop specific procurement methods in compliance with £200.320, “Methods of procurement to be followed.” Condition and Context: The Organization has no documented procedures over the procurement process, contractor selection, or established methods in place to assure free and open competition as required by the Procurement Standards contained in the Uniform Guidance. Cause: Lack of understanding relating to the requirements of federal awards and loans considered to be financial assistance under the Uniform Guidance. Effect: Lack of documented controls over the Organization’s procurement process creates a material weakness in internal controls over compliance. Questioned Costs: None Recommendation: Management should become familiar with the Uniform Guidance, and in particular, the application section on Procurement, and seek additional training for those staff involved in all phases of the procurement process. Views of Responsible Officials and Planned Corrective Actions: We are creating a job description for a financial analyst. Part of this role will be to implement the recommendation, including development of bid specifications, participation in the selection of supplies and contractors, and monitoring/documenting results.
Finding 2018 - 001 Procurement, Suspension & Debarment (I) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Non-federal entities must follow the procurement standards set out at 2 CFR Sections 200.318 through 200.326. They must use their own documented procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statues and the procurement requirements identified in 2 CFR Part 200 as described above. Finding/Condition: The procurement policies and procedures were found lacking as to the bidding and retaining process. We could not locate certain files indicating that the procurement requirements had been followed. In addition, we could not locate certain files indicating the debarment procedures had been properly followed per the requirements. Cause: Management lack of time to establishing a policy and procedure regarding this requirement. Effect: The lack of policies and procedures in this area may cause the Clinic to be out of compliance with this procurement, suspension and debarment requirement. A lack of competitive bidding may overstate allowable costs and a lack of debarment procedures may allow debarred vendors in providing material, supplies and services. Questioned Cost: None Recommendation: The Clinic should establish sound policies and procedures which conform to federal requirements for procurement, suspension and debarment. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Finding 2018-002 – Lack of Policies/Procedures & Documentation Related to Procurement/Suspension and Debarment (Material Weakness in Internal Controls over Compliance – Federal Program CFDA 10.766/10.780 Community Facilities Loans and Grants Cluster) Criteria: 2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, £200.318 requires that the auditee must have and use documented procurement procedures for the purchase/acquisition of any property or services under a Federal award. These must include written standards of conduct covering conflicts of interest, consideration of the most economical purchase, rationale for the method of procurement, selection of contractors including whether they have been barred from doing business with the federal government, and the basis for the contract price. Also, £200.319 requires all procurement transactions be conducted in a manner that provides full and open competition, and develop specific procurement methods in compliance with £200.320, “Methods of procurement to be followed.” Condition and Context: The Organization has no documented procedures over the procurement process, contractor selection, or established methods in place to assure free and open competition as required by the Procurement Standards contained in the Uniform Guidance. Cause: Lack of understanding relating to the requirements of federal awards and loans considered to be financial assistance under the Uniform Guidance. Effect: Lack of documented controls over the Organization’s procurement process creates a material weakness in internal controls over compliance. Questioned Costs: None Recommendation: Management should become familiar with the Uniform Guidance, and in particular, the application section on Procurement, and seek additional training for those staff involved in all phases of the procurement process. Views of Responsible Officials and Planned Corrective Actions: We are creating a job description for a financial analyst. Part of this role will be to implement the recommendation, including development of bid specifications, participation in the selection of supplies and contractors, and monitoring/documenting results.