EIN: 237022588
UEI: M1N9BTD3SZF9
Data as of August 25, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 20, 2025. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 20, 2025 (340 days ago).
What is a management decision? →The Organization has a procurement policy, which requires full and open competition for purchases of goods and services in excess of a certain threshold. We noted one instance where procurement procedures were not performed on a purchase in excess of the threshold during the fiscal year. Cause: The Organization's procurement policy is not properly updated to be in conformance with Federal cost principals. Effect or Potential Effect: Purchases of goods and services could be made above the prevailing market rates if the prescribed procurement procedures are not adhered to, and thus, there lies the potential that the Organization will not receive the best value for its purchases. The procurement process should also allow for an evaluation of potential conflicts of interest with prospective vendors and contractors. Furthermore, failure to perform the proper procurement procedures could result in disallowance of Federal expenditures based on lack of fair competition. Questioned Costs: $36,000. Context: The Organization has a procurement policy that is not in compliance with Federal cost principals, and hence, noncompliance with Federal standards. Our audit work in this area consisted of internal control testwork over a random sample of expenditures, as well as substantive testwork over transactions above a defined threshold from select expense accounts that were charged to the Federal program. We consider our samples to be representative of the respective populations, and thus, are statistically valid samples. Identification as a Repeat Finding, if Applicable: Not a repeat finding. Recommendation: We recommend that the Organization ensure its policy is updated and in line with Federal cost principals, and distributed and communicated in a formal manner to its employees, and that management properly enforce compliance with its policy. All procurement actions should be clearly documented in writing and maintained in the vendor or contractor files.
Show full finding ▾Hide full finding ▴Finding 2024-001: Procurement (Significant Deficiency) Information on the Federal Program: All Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in Standards for Internal Control in the Federal Government issued by the Comptroller General of the United States or the internal Control Integrated Framework, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition of property or services required under a Federal award must be conducted in a manner providing full and open competition consistent with the standards of this section and §200.320. The non-Federal entity must have written procedures for procurement transactions." Condition: The Organization has a procurement policy, which requires full and open competition for purchases of goods and services in excess of a certain threshold. We noted one instance where procurement procedures were not performed on a purchase in excess of the threshold during the fiscal year. Cause: The Organization's procurement policy is not properly updated to be in conformance with Federal cost principals. Effect or Potential Effect: Purchases of goods and services could be made above the prevailing market rates if the prescribed procurement procedures are not adhered to, and thus, there lies the potential that the Organization will not receive the best value for its purchases. The procurement process should also allow for an evaluation of potential conflicts of interest with prospective vendors and contractors. Furthermore, failure to perform the proper procurement procedures could result in disallowance of Federal expenditures based on lack of fair competition. Questioned Costs: $36,000. Context: The Organization has a procurement policy that is not in compliance with Federal cost principals, and hence, noncompliance with Federal standards. Our audit work in this area consisted of internal control testwork over a random sample of expenditures, as well as substantive testwork over transactions above a defined threshold from select expense accounts that were charged to the Federal program. We consider our samples to be representative of the respective populations, and thus, are statistically valid samples. Identification as a Repeat Finding, if Applicable: Not a repeat finding. Recommendation: We recommend that the Organization ensure its policy is updated and in line with Federal cost principals, and distributed and communicated in a formal manner to its employees, and that management properly enforce compliance with its policy. All procurement actions should be clearly documented in writing and maintained in the vendor or contractor files.
Views of Responsible Officials: The Organization will update its procurement policy to be in conformance with Federal cost principles for approval at the next Board Meeting on February 24, 2025. Supporting operating procedures will be reviewed and adjusted accordingly to ensure compliance with the policy by February 28, 2025. The situation resulting in this finding was for the procurement of support services for a new electronic health records system which was successfully implemented using the services purchased at a reasonable cost; however, the procedures followed by previous staff did not fully comply with the Organization's policies and procedures nor the Federal cost principles. The Organization has since implemented additional procedures to ensure documentation for competitive bids and justification for all purchases to comply with Federal requirements enhancing the Organization's internal procedures. The Organization will do a full review of the Federal cost principles and suggested procedures to ensure full compliance and implement new policies and additional procedures, as necessary, by February 28. 2025.
FAC accepted this audit on February 14, 2022 — management decision was due August 14, 2022.
During the year under audit, we noted two instances in which the Organization did not comply with their policy regarding Suspension and Debarment, and the screening process was not completed for these two vendors. The failure to screen such parties increases the possibility that U.S. Government funds may inadvertently be provided to individuals or organizations deemed to be excluded by the U.S. Government. Cause: The Organization did not consistently comply with their internal polices and procedures regarding the screening process. Effect or Potential Effect: Failure to screen potential vendors, suppliers, employees, fellows or other non-contracted federal transactions against the suspended and debarred list increases the possibility that U.S. Government funds may inadvertently be provided to individuals or organizations deemed to be excluded parties by the U.S. Government. Questioned Costs: None Context: 2 of 2 vendors sampled had payments made by the Organization without consistently performing the screening process. Recommendation: We recommend that management be diligent in communicating these screening policies and procedures to employees of the organization, and it should stress the importance of documenting compliance with the ?Suspension and Debarment? provisions. These screenings should be completed prior to entering into the transactions or making payments. Responsible Official: Peter Lowet, Executive Director Anticipated Completion Date: April 30, 2022
Show full finding ▾Hide full finding ▴Finding 2021-001: Screening for Suspension and Debarment Criteria or Specific Requirement: As stated in 2 CFR 200.212 and the 2021 Compliance Supplement, recipients of U.S. Government funds must adhere to specific requirements on screening all potential vendors, suppliers, employees and sub-contractors/grantees to ensure the organizations are not conducting business with excluded parties (as defined by the U.S. Government); the screening must be documented in writing. Condition: During the year under audit, we noted two instances in which the Organization did not comply with their policy regarding Suspension and Debarment, and the screening process was not completed for these two vendors. The failure to screen such parties increases the possibility that U.S. Government funds may inadvertently be provided to individuals or organizations deemed to be excluded by the U.S. Government. Cause: The Organization did not consistently comply with their internal polices and procedures regarding the screening process. Effect or Potential Effect: Failure to screen potential vendors, suppliers, employees, fellows or other non-contracted federal transactions against the suspended and debarred list increases the possibility that U.S. Government funds may inadvertently be provided to individuals or organizations deemed to be excluded parties by the U.S. Government. Questioned Costs: None Context: 2 of 2 vendors sampled had payments made by the Organization without consistently performing the screening process. Recommendation: We recommend that management be diligent in communicating these screening policies and procedures to employees of the organization, and it should stress the importance of documenting compliance with the ?Suspension and Debarment? provisions. These screenings should be completed prior to entering into the transactions or making payments. Responsible Official: Peter Lowet, Executive Director Anticipated Completion Date: April 30, 2022
Views of Responsible Officials: Management agrees that there was an oversight regarding vendor screening, and reaffirms our commitment to internal controls. The planned corrective actions include: ? Review and revision as appropriate of the relevant internal control policy regarding screening for Suspension and Debarment. ? Assurance that existing vendors that must be screened according to the relevant policy will be screened within the next 9 months and prior to their contract renewal. ? Compliance with the revised policy for all new vendors prior to contractual agreement.
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