Finding 544481 (2024-003)

Significant Deficiency
Requirement
I
Questioned Costs
$1
Year
2024
Accepted
2025-03-31

AI Summary

  • Core Issue: The Organization failed to provide documentation supporting the procurement method for a $4,000 expense.
  • Impacted Requirements: This finding violates procurement standards outlined in 2 CFR sections 200.318 through 200.327.
  • Recommended Follow-Up: Conduct training for staff to ensure proper documentation retention for procurement processes.

Finding Text

Finding 2024-003: Lack of Support for Procurement Requirement U.S. Department of Health and Human Services Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) Federal Award Year: 2024 Repeat Finding: No Criteria: The Organization must follow the procurement standards set out in 2 CFR sections 200.318 through 200.327. The Organization must use its 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. Condition: While testing the procurement requirement for micro purchases, we noted there was one sample selection for which the Organization did not have documentation to support whether the procurement method used was appropriate. Cause: The Organization did not consistently maintain documentation to support the procurement method used. The documentation was maintained by one individual within the Organization, and that individual is no longer with the Organization. Effect: The Organization was not able to provide supporting documentation for one out of the 40 sample selections tested. The missing supporting documentation was for an expense in the amount of $4,000. Questioned Costs: $4,000 Context: We could not verify the appropriate procurement method was used for one out of 40 sample selections. Total likely questioned costs are estimated to be approximately $38,000. Recommendation: We recommend that additional training of responsible staff be performed to ensure that all documentation related to procurement is retained. View of responsible officials of the auditee: Management agrees with the finding and recommendation.

Corrective Action Plan

Identifying Number: 2024-001 Audit Finding: Accounting for Pharmacy 340B Drug Pricing Program Transactions. While testing the 340B Program, revenue and accounts receivable, we identified the following errors: • The Organization overstated 340B Program accounts receivable and revenue by double-counting a 340B Program transaction in the amount of $213,887. • The Organization understated 340B Program accounts receivable and revenue by $45,038 by not properly recording a transaction with a pharmacy. • The Organization overstated 340B Program revenue and professional services expense by $1,111,252 by posting an incorrect adjustment to true-up revenue and expense for dispensing, processing and administrative fees associated with the 340B Program. Corrective Action Taken: The Controller will utilize program data reports to perform reconciliations periodically. The reconciliations will be reviewed by the VP of Finance and stored. Additionally, the Revenue Cycle Manager and the VP of Finance will assist and monitor TPA’s setup and conditions for proper program management. This will be implemented by June 30, 2025. Identifying Number: 2024-002 Audit Finding: Inadequate Internal Controls Over Payroll Transactions. In May 2024, the Organization failed to restrict the modification of payroll reports subsequent to approval. There was no final check performed to ensure that the final submitted payroll report agreed with the approved version. Corrective Action Taken: By June 2024, the Finance Director created additional checks and balances to ensure integrity of payroll. The Director will provide a trend analysis of payroll data for each payroll for the approval process. The analysis will show changes in employee pay and trends. We will also compare the final payroll totals with the website verification after submission to ensure the totals reviewed match what was submitted. Identifying Number: 2024-003 Audit Finding: While testing the procurement requirement for micro purchases, we noted there was one sample selection for which the Organization did not have documentation to support whether the procurement method used was appropriate. Corrective Action Taken: By June 30, 2025, the Operations team and the Accounts Payable Coordinator will maintain a centralized database of vendor contracts, bids, and other information regarding purchases. To ensure continuity through changes in personnel, Tapestry will store the data on the shared drives, allowing for a repository to persist over time. Purchases, contracts, and associated back up will be monitored by both Operations and Finance teams and will be assisted by Office Managers who may perform some ordering.

Categories

Questioned Costs Procurement, Suspension & Debarment

Other Findings in this Audit

  • 544482 2024-003
    Significant Deficiency
  • 544483 2024-003
    Significant Deficiency
  • 1120923 2024-003
    Significant Deficiency
  • 1120924 2024-003
    Significant Deficiency
  • 1120925 2024-003
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $1.49M
93.527 Grants for New and Expanded Services Under the Health Center Program $1.10M
93.526 Grants for Capital Development in Health Centers $436,492
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $363,274
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $284,902
93.994 Maternal and Child Health Services Block Grant to the States $282,432
93.788 Opioid Str $274,680
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $215,023
93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges $74,199
93.217 Family Planning Services $62,000
93.576 Refugee and Entrant Assistance Discretionary Grants $61,465
93.247 Advanced Nursing Education Workforce Grant Program $25,425