EIN: 237112026
UEI: XK7XLZL3DEG8
Data as of August 25, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on February 21, 2024. 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 August 21, 2024 (735 days ago).
What is a management decision? →For the six reports required to be submitted to the funding agency that were sampled, one report did not have accurate information reported. Questioned Costs: None. Criteria: The Organization must have adequate controls implemented over its preparation and submission of reports to ensure accurate and complete reporting. Cause: The Organization’s review process over its preparation and submission of required reports failed. Effect: With inaccurate information reported, the Organization could be in noncompliance with reporting standards set by the grant. Recommendation: We recommend the Organization strengthen its review process over its reporting requirements. Management Response: Management agrees with the finding. Procedures are being implemented to ensure a review of the program’s reports is conducted after all accounting for the reports’ periods have been finalized.
Show full finding ▾Hide full finding ▴Finding Number 2023-001 Internal Controls over Reporting, United States Department of Health and Human Services, Substance Abuse Prevention and Treatment Block Grant (SABG), ALN 93.959, October 1, 2022 through September 30, 2023 (Significant Deficiency). Statement of Condition: For the six reports required to be submitted to the funding agency that were sampled, one report did not have accurate information reported. Questioned Costs: None. Criteria: The Organization must have adequate controls implemented over its preparation and submission of reports to ensure accurate and complete reporting. Cause: The Organization’s review process over its preparation and submission of required reports failed. Effect: With inaccurate information reported, the Organization could be in noncompliance with reporting standards set by the grant. Recommendation: We recommend the Organization strengthen its review process over its reporting requirements. Management Response: Management agrees with the finding. Procedures are being implemented to ensure a review of the program’s reports is conducted after all accounting for the reports’ periods have been finalized.
2023-001 Inaccurate information reported Revenue was overstated on Quarter 4 Deliverable FN-403 for SUBG profit corridor report. The final general ledger of October 26, 2023 did not tie to the profit corridor report submitted on October 16, 2023, as prepared by Cynthia Duncan and approved by Aimee Graves. The Profit corridor on the original report was -1%. A corrected report was submitted on November 09, 2023, by Cynthia Duncan and approved by Aimee Graves. The corrected profit corridor was -3%. The Deliverable should not be filed until the general ledger is finalized.
FAC accepted this audit on January 10, 2023 — management decision was due July 10, 2023.
The Organization does not have adequate controls over user access to its electronic health records used for services funded by SABG.Questioned Costs:None.Criteria:The Organization must comply with activities allowed or unallowed and allowable costs/cost principles standards as set by the U.S. Department of Health and Human Services.Cause:The Organization did not adequately set controls over user access to its electronic health records.Effect:With the absence of adequate controls, the Organization could bill for services not allowed by the grant.Recommendation:We recommend the Organization make the necessary changes to ensure user access to its electronic health record is adequately documented and reviewed.Management Response:Management agrees with the finding. Procedures are being implemented to ensure a level of review over changes to the Organization?s electronic health records.
Show full finding ▾Hide full finding ▴Finding Number 2022-001 Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles, Substance Abuse Prevention and Treatment Block Grant (SABG), ALN 93.959, October 1, 2021 through September 30, 2022 (Significant Deficiency).Statement of Condition:The Organization does not have adequate controls over user access to its electronic health records used for services funded by SABG.Questioned Costs:None.Criteria:The Organization must comply with activities allowed or unallowed and allowable costs/cost principles standards as set by the U.S. Department of Health and Human Services.Cause:The Organization did not adequately set controls over user access to its electronic health records.Effect:With the absence of adequate controls, the Organization could bill for services not allowed by the grant.Recommendation:We recommend the Organization make the necessary changes to ensure user access to its electronic health record is adequately documented and reviewed.Management Response:Management agrees with the finding. Procedures are being implemented to ensure a level of review over changes to the Organization?s electronic health records.
2022-001 Excessive number of Super Users in KIPU medical record system and Alli Lippard's (Billing Manager) practice of changing billing codes without supervision.The Haven reduced the number of Super Users to three Suzi Armenta (IT Manager), Kristin Lindberg (Quality Director), and Allie Lippard on November 18, 2022.Allie Lippard sends a spreadsheet to Cynthia Duncan (Finance Director), Ryan Olson (Acting Clinical Director), and Jody Little (Outpatient Program Manager) documenting code changes required and the reason for the change. Cynthia Duncan will affirm the changes in an email response.When the charges are transferred to the Billing system Allie Lippard will run a report showing the charges in the Billing system and Cynthia Duncan will affirm via email that the charges match the modified data set. This process will be complete December 19th, 2022.
For the six reports required to be submitted to the funding agency that were sampled, there was no review.Questioned Costs:None.Criteria:The Organization must have adequate controls implemented over its preparation and submission of reports to ensure accurate and complete reporting.Cause:The Organization does not have a review process in its preparation and submission of required reports.Effect:With the absence of adequate controls, the Organization could be in noncompliance with reporting standards set by the grant.Recommendation:We recommend the Organization implement a review process over its reporting process.Management Response:Management agrees with the finding. Procedures are being implemented to ensure a level of review is implemented over the program?s reports.
Show full finding ▾Hide full finding ▴Finding Number 2022-002 Internal Controls over Reporting, Substance Abuse Prevention and Treatment Block Grant (SABG), ALN 93.959, October 1, 2021 through September 30, 2022 (Significant Deficiency).Statement of Condition:For the six reports required to be submitted to the funding agency that were sampled, there was no review.Questioned Costs:None.Criteria:The Organization must have adequate controls implemented over its preparation and submission of reports to ensure accurate and complete reporting.Cause:The Organization does not have a review process in its preparation and submission of required reports.Effect:With the absence of adequate controls, the Organization could be in noncompliance with reporting standards set by the grant.Recommendation:We recommend the Organization implement a review process over its reporting process.Management Response:Management agrees with the finding. Procedures are being implemented to ensure a level of review is implemented over the program?s reports.
2022-002 Cynthia Duncan prepares SABG reporting and affirms their validity.Cynthia Duncan prepares the reports and Aimee Graves (Executive Director) affirms their validity on a monthly or quarterly basis as reports are due. This process went into effect December 1, 2022.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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