Finding 4447 (2018-001)

Significant Deficiency
Requirement
I
Questioned Costs
-
Year
2018
Accepted
2023-12-15
Audit: 6872
Organization: First Person Care Clinic, Inc. (NV)

AI Summary

  • Core Issue: Internal controls over procurement are inadequate, leading to potential non-compliance with federal standards.
  • Impacted Requirements: Failure to follow procurement standards outlined in 2 CFR Sections 200.318-326, including proper bidding and debarment procedures.
  • Recommended Follow-Up: Develop and implement comprehensive policies and procedures that align with federal procurement requirements.

Finding Text

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.

Corrective Action Plan

Action Plan to Address Policy Updates and Implementation (Finding 2018-001): a. Review and Update Policies: Begin by conducting a comprehensive review of existing policies, particularly those related to procurement, suspension, and debarment. Ensure these policies align with the latest HRSA requirements and federal regulations. b. Engage a Policy Consultant: Seek the expertise of a policy consultant or legal counsel well-versed in healthcare compliance and HRSA regulations to assist in policy revision. c. Policy Training: Develop a training program to educate staff, especially key personnel like the CEO and CFO, on the updated policies. This training should emphasize the significance of compliance and the potential consequences of non-compliance. d. Implementation Oversight: Appoint a Compliance Officer responsible for overseeing the implementation of updated policies and procedures. This officer should regularly audit and monitor adherence to these policies. e. Documentation and Reporting: Implement a robust documentation system to track policy adherence and any deviations. Ensure that timely and accurate reports are generated for review by internal committees and the board. f. Board and Committee Involvement: Enhance board and committee involvement in the oversight of policy compliance. Provide regular updates and reports to these entities to keep them informed and engaged in the compliance process. g. Continuous Monitoring: Establish a continuous monitoring process to identify any policy-related deficiencies promptly. Regularly assess the effectiveness of policies and make necessary adjustments. h. External Audit: Schedule an external audit ahead of time by an independent auditor or agency to ensure objectivity and compliance with HRSA standards. i. Communication: Promote a culture of compliance through effective communication channels. Encourage employees at all levels to report potential violations or concerns without fear of retaliation. j. Periodic Review: Commit to a periodic review of policies, at least annually, to ensure they remain current and aligned with any evolving HRSA regulations or federal mandates.

Categories

Procurement, Suspension & Debarment

Other Findings in this Audit

  • 4448 2018-002
    Significant Deficiency
  • 580889 2018-001
    Significant Deficiency
  • 580890 2018-002
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.224 Health Resources and Services Administration Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $754,162
93.297 Nevada Primary Care Association: Teen Pregnancy Prevention $39,996