Finding 1230001 (2025-003)

Material Weakness Repeat Finding
Requirement
I
Questioned Costs
-
Year
2025
Accepted
2026-09-16
Audit: 411216
Organization: Papa Ola Lokahi (HI)
Auditor: KKDLY LLC

AI Summary

  • Core Issue: The Organization failed to follow proper procurement methods as required by Uniform Guidance 2 CFR §200.320, leading to potential compliance issues.
  • Impacted Requirements: Noncompetitive procurements were made without meeting necessary criteria, violating federal standards and risking allowable cost issues.
  • Recommended Follow-Up: Ensure the incorporation of procurement standards into policies and procedures, and maintain detailed documentation of procurement processes to achieve compliance by the next audit.

Finding Text

Material Weakness Finding No. 2025-003: Procurement Policies U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. U.S. Department of Health and Human Services Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. Criteria The Uniform Guidance 2 CFR §200.320 sets forth the methods of procurement to be followed in the acquisition of property or services required under a Federal award or subaward, which includes formal purchase methods such as proposal or bids when the value of the property or services under a Federal financial assistance award exceeds a certain threshold, as defined. Furthermore, 2 CFR §200.320(c) provides specific circumstances in which noncompetitive procurement can be used. Condition During our audit, we noted that the Organization made subawards to entities which were subject to a formal purchase method, for which competitive processes for selection were not performed, nor was documentation of the specific criteria of 2 CFR §200.320(c) met to support noncompetitive procurements maintained. Cause Management had not updated its policies and procedures to incorporate certain pertinent sections of the procurement standards of the Uniform Guidance.Effect The lack of procurement standards in accordance with the Uniform Guidance may result in allowable cost issues. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediately previous audit as Finding No. 2024-003. Recommendation We again recommend that the Organization incorporate the procurement standards of the Uniform Guidance to its policies and procedures manual to ensure compliance with Federal standards, including 2 CFR §200.318(h) which stipulates that sufficient detail of the history of the procurement must be maintained, including the selection of the contractor. Views of Responsible Officials and Corrective Action The Organization acknowledges incorporation of the procurement standards of the Uniform Guidance to its policies and procedures to ensure compliance with Federal standards, including 2 CFR §200.318(h). The Organization concurs with the prior year (2024-003) and current year renumbered recommendation (2025-003), and highlights its ongoing progressive and corrective implementation of policy and process actions. For context, the Organization’s progressive and corrective actions as of the fiscal year ended (FYE) June 30, 2024 report included the following:A. Financial Policies – May 2025. Completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. In addition, when applicable, documenting procurement circumstances, processes, decisions and CEO approval was implemented via memo(s) to the procurement file (MTPF). B. Procurement Related Processes – May 2025. Initiated use of MTPF, and process implementation of Request(s) for Professional Services Qualifications, Request(s) for Professional Services, Request(s) for Proposal. C. HRSA Policies – July 2025. Developed HRSA related policies re: implementation of HRSA policies; executive performance evaluation, non-executive performance evaluation, executive compensation, non-executive compensation, timesheets, suspension & debarment procedure, financial management system, legislative mandates, legislative mandates process & procedure and cash management for federal draws and return of funds.D. Board Policy Provision & Awareness – August 2025. Informed the Board about the progress of the Organization’s policy framework, including the above policies. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. B. Discussed with respective program director(s), the application of initiation, consideration, decision, documentation and monitoring phased activities. C. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. D. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). E. Updated procurement processes for emergency disaster recovery and support of community needs, including MTF documentation. Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date.

Corrective Action Plan

Finding No. 2025-003: Procurement Policies Views of Responsible Officials and Corrective Action The Organization acknowledges incorporation of the procurement standards of the Uniform Guidance to its policies and procedures to ensure compliance with Federal standards, including 2 CFR §200.318(h). The Organization concurs with the prior year (2024-003) and current year renumbered recommendation (2025-003),and highlights its ongoing progressive and corrective implementation of policy and process actions. For context, the Organization’s progressive and corrective actions as of the fiscal year ended (FYE) June 30, 2024 report included the following: A. Financial Policies – May 2025. Completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. In addition, when applicable, documenting procurement circumstances, processes, decisions and CEO approval was implemented via memo(s) to the procurement file (MTPF). B. Procurement Related Processes – May 2025. Initiated use of MTPF, and process implementation of Request(s) for Professional Services Qualifications, Request(s) for Professional Services, Request(s) for Proposal. C. HRSA Policies – July 2025. Developed HRSA related policies re: implementation of HRSA policies; executive performance evaluation, non-executive performance evaluation, executive compensation, non-executive compensation, timesheets, suspension & debarment procedure, financial management system, legislative mandates, legislative mandates process & procedure and cash management for federal draws and return of funds. D. Board Policy Provision & Awareness – August 2025. Informed the Board about the progress of the Organization’s policy framework, including the above policies. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. B. Discussed with respective program director(s), the application of initiation, consideration, decision, documentation and monitoring phased activities. C. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. D. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). E. Updated procurement processes for emergency disaster recovery and support of community needs, including MTF documentation. Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date Finding No. 2025-003: Procurement Policies Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D., Chief of Staff.

Categories

Procurement, Suspension & Debarment

Other Findings in this Audit

  • 1229985 2025-002
    Material Weakness Repeat
  • 1229986 2025-003
    Material Weakness Repeat
  • 1229987 2025-004
    Material Weakness Repeat
  • 1229988 2025-005
    Material Weakness Repeat
  • 1229989 2025-006
    Material Weakness Repeat
  • 1229990 2025-002
    Material Weakness Repeat
  • 1229991 2025-003
    Material Weakness Repeat
  • 1229992 2025-004
    Material Weakness Repeat
  • 1229993 2025-005
    Material Weakness Repeat
  • 1229994 2025-006
    Material Weakness Repeat
  • 1229995 2025-002
    Material Weakness Repeat
  • 1229996 2025-003
    Material Weakness Repeat
  • 1229997 2025-004
    Material Weakness Repeat
  • 1229998 2025-005
    Material Weakness Repeat
  • 1229999 2025-006
    Material Weakness Repeat
  • 1230000 2025-002
    Material Weakness Repeat
  • 1230002 2025-004
    Material Weakness Repeat
  • 1230003 2025-005
    Material Weakness Repeat
  • 1230004 2025-006
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.932 NATIVE HAWAIIAN HEALTH CARE SYSTEMS $8.06M
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $3.01M
84.362A NATIVE HAWAIIAN EDUCATION $443,816
93.837 CARDIOVASCULAR DISEASES RESEARCH $134,292
93.387 NATIONAL AND STATE TOBACCO CONTROL PROGRAM $94,036
93.859 BIOMEDICAL RESEARCH AND RESEARCH TRAINING $53,544
93.110 SPECIAL PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $24,603
93.185 IMMUNIZATION RESEARCH, DEMONSTRATION, PUBLIC INFORMATION AND EDUCATION TRAINING AND CLINICAL SKILLS IMPROVEMENT PROJECTS $17,998
93.307 NATIONAL AND STATE TOBACCO CONTROL PROGRAM $14,000
93.304 RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH $10,765
45.311 NATIVE AMERICAN AND NATIVE HAWAIIAN LIBRARY SERVICES $9,260
93.421 STRENGTHENING PUBLIC HEALTH SYSTEMS AND SERVICES THROUGH NATIONAL PARTNERSHIPS TO IMPROVE AND PROTECT THE NATION€™S HEALTH $6,000