Finding 1166169 (2025-002)

Material Weakness Repeat Finding
Requirement
I
Questioned Costs
-
Year
2025
Accepted
2025-12-22
Audit: 377069
Organization: Compass Health and Subsidiaries (WA)
Auditor: CLARK NUBER PS

AI Summary

  • Core Issue: The Organization lacks a formal procurement policy, leading to noncompliance with federal regulations regarding procurement and documentation.
  • Impacted Requirements: Failure to meet criteria outlined in 2 CFR sections 200.318 to 200.320 and restrictions on contracting with debarred or suspended parties under 2 CFR part 180.
  • Recommended Follow-Up: Develop and implement a comprehensive procurement policy that aligns with Uniform Guidance and ensures proper documentation of procurement history.

Finding Text

Finding 2025-002 Significant deficiency in internal controls over compliance and noncompliance with procurement and suspension and debarment procedures meeting the requirements of the Uniform Guidance. Federal Agency: Department of Health and Human Services Program Title: Congressional Directives Assistance Listing Number: 93.493 Award Number: CE1HS47357-01-00 Award Period: September 1, 2022 - August 31, 2025 Criteria 2 U.S. Code of Federal Regulations (CFR) 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires a non-Federal entity that has expended federal awards to have written policies pertaining to its federal grants for procurement and that the history of each procurement is documented in accordance with 2 CFR section 200.318 to 200.320. Further, the regulations in 2 CFR part 180 restrict making Federal awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from receiving or participating in Federal awards. Condition/Context for Evaluation The Organization received and utilized the federal award to pay for general contractor services for Phase II of a multi-phase construction project that was ongoing at the time of the award. The general contractor was selected as part of a competitive RFQ process for Phase I of the construction prior to notice of the award. A cost and price analysis was completed on the general contractor during the RFQ process. During predevelopment, the general contractor selected for Phase I was contracted for consulting work for scoping Phase II of the project. The general contractor and Organization solicited competitive bids from subcontractors and performed a cost/price analysis that was used for subcontractor selection. A stipulated sum contract was signed with the general contractor based substantially on the competitive bids received from subcontractors. As a result, the Organization ultimately elected to utilize a noncompetitive procurement method for the selection of the general contractor for Phase II of the construction project, on the basis that the procurement could only be obtained from a single source. This was determined due to the specialized nature of the building itself, as well as the accumulated knowledge that the general contractor had from Phase I of the project, and consulting on the predevelopment of Phase II. Ultimately, the Organization did not have a procurement policy in place that specifically covered the criteria and documentation requirements for a noncompetitive procurement required under the Uniform Guidance. As a result, the Organization did not have a process in place that resulted in compliance with the Uniform Guidance, including the maintenance of records to detail the history of the procurement in accordance with 2 CFR 200.318 to 1 CFR 200.320 Cause The Organization did not have a procurement policy or internal controls in place to ensure that the Organization’s procurement activities were done in accordance with the Uniform Guidance and controls were in place to retain documentation of the history of the procurement. Effect or Potential Effect The Organization entered into agreements to procure goods and services for which appropriate documentation was not retained to support the history of the procurement. Questioned Costs $0 Repeat Finding No

Corrective Action Plan

Corrective Action Plan Contact Person(s): Janet Carbary, Deana Gilpin Management agrees with this finding and recognizes the need to strengthen internal controls over purchasing processes to ensure compliance with Uniform Guidance requirements (§200.317–§200.326; §200.213). To address the deficiency, the Organization will implement the following actions: 1. Update Purchasing Policies and Procedures o Purchasing policies will be revised to clearly incorporate Uniform Guidance requirements, including competitive bidding thresholds, procurement method selection, and documentation standards. o Policies will explicitly require verification of suspension and debarment status for all vendors receiving federal funds. 2. Implement Mandatory Suspension and Debarment Verification o Staff will be required to document verification through SAM.gov or other approved sources before awarding or renewing contracts funded by federal awards. o A verification will be maintained and reviewed by Finance leadership. 3. Enhance Procurement Documentation Controls o Leadership will ensure all federal purchases meet the requirement below before purchase approval. • Competitive purchasing requirements are met • Cost/price analyses are documented when required • Suspension/debarment verifications are completed and retained 4. Training for Finance Staff o Staff involved in purchasing, contract approval, and grant management will receive training on Uniform Guidance procurement rules and suspension/debarment requirements. 5. Periodic Internal Monitoring o Revenue accountant will monitor expenses related to federal programs monthly to ensure compliance. o Senior management will be notified if corrective steps are needed. Anticipated Completion Date: December 31, 2025 Responsible Officials: • Chief Financial Officer (CFO) • Accounting Manager • Director of Financial Planning

Categories

Procurement, Suspension & Debarment

Programs in Audit

ALN Program Name Expenditures
93.493 CONGRESSIONAL DIRECTIVES $2.00M
14.239 HOME INVESTMENT PARTNERSHIPS PROGRAM $682,793
14.238 SHELTER PLUS CARE $533,781
16.575 CRIME VICTIM ASSISTANCE $380,322
14.157 SUPPORTIVE HOUSING FOR THE ELDERLY $327,968
14.871 SECTION 8 HOUSING CHOICE VOUCHERS $242,880
14.195 PROJECT-BASED RENTAL ASSISTANCE (PBRA) $168,335
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $160,467
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $115,000
93.669 CHILD ABUSE AND NEGLECT STATE GRANTS $97,304
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $25,000