Federal Agency: U.S. Department of Housing and Urban Development U.S. Department of Health and Human Services Federal Program Name: Continuum of Care Program Center for Substance Abuse Treatment - Certified Community Behavioral Health Clinic Assistance Listing Number: 14.267 93.696 Direct Federal Award Program: PA0029L3T002316 - Tioga Arms PA0568L3T002308 - Shelton Court 22TI85374A – Certified Community Behavioral Health Clinic Type of Finding: - Significant Deficiency in Internal Control over Compliance - Other Matters Condition: As part of our audit procedures over the Organization’s procurement policy and the small purchase requirements under 2 CFR 200.320(a)(2), we sampled a total of five vendors who incurred costs exceeding $10,000 for each of the two major programs. For three of the five vendors selected, management was unable to provide written documentation demonstrating that price or rate quotations were obtained from an adequate number of qualified sources (generally 2-3 quotes) for purchases above the micro-purchase threshold ($10,000) and below the Simplified Acquisition Threshold ($250,000). This documentation should have included the names of suppliers contacted, prices quoted, and the justification for vendor selection. Recommendation: We recommend management update its policies and procedures over procurement to ensure compliance with 2 CFR Part 200. This includes requiring and retaining documentation supporting the use of small purchase procedures, obtaining price or rate quotations from an adequate number of qualified sources, and monitoring vendor expenditures on an aggregate basis to ensure the appropriate procurement method is applied. Management should also provide training for staff responsible for procurement activities to promote consistent compliance with federal requirements. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action taken in response to finding: Management acknowledges the deficiency related to procurement documentation and compliance. While the Organization has procurement practices in place, documentation supporting the solicitation of price or rate quotations from an adequate number of qualified sources was not consistently maintained for certain purchases during the audit period. In certain instances, vendor selection was influenced by the need to ensure continuity of care and avoid disruption to critical services provided to clients. As a result, management prioritized maintaining established vendor relationships to support uninterrupted service delivery; however, formal documentation supporting this rationale was not consistently retained in accordance with procurement requirements. To address this matter, management will update and formalize procurement policies and procedures to ensure full compliance with federal requirements. This will include clearly defined documentation standards for all purchases exceeding the micro-purchase threshold, including retention of vendor quotes, identification of suppliers contacted, and justification for vendor selection—including instances where continuity of care is a determining factor. In addition, training will be provided to all staff involved in procurement activities to reinforce compliance expectations and documentation requirements. Management expects these corrective actions to be implemented in the current fiscal year and will conduct periodic reviews to ensure adherence and ongoing compliance. Name of the contact person responsible for corrective action: Dr. Deja Gilbert, PhD, MDA, FACHE, LPC, LMHC, President and CEO dgilbert@gaudenzia.org Planned completion date for corrective action plan: June 30, 2026