EIN: 237305106
UEI: F7LUA7LXRNP6
Audited by: BDMP ASSURANCE, LLP
Oversight agency: 93 [Department of Health and Human Services]
View federal awards & risk assessment →
Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on January 29, 2026. 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 July 29, 2026 (33 days ago).
What is a management decision? →During testing of payroll allocated to the federal program, 1 of the 25 employees tested had salary charges which exceeded the Executive Level II compensation cap. Upon further review of the full population, a total of 3 employees were identified whose salary charges to the federal program exceeded the cap. Cause: The Organization relied on an informal, manual process to identify employees at or near the Executive Level II compensation cap. This process was not supported by documented policies, defined thresholds, or supervisory review controls. Effect: Unallowable salary amounts were initially charged to the grant. However, the Organization was able to identify other allowable expenditures sufficient to support the total amount of grant funds drawn. Questioned Costs: None Repeat Finding: No Recommendation: We recommend the Organization implement a formalized internal control process to monitor and enforce compliance with the Executive Level II compensation cap. This should include documented procedures for identifying employees subject to the cap, periodic monitoring of compensation charged to federal programs, and evidence of supervisory review to help ensure amounts in excess of the cap are excluded from allowable costs and appropriately allocated to nonfederal funding sources. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. The Organization has implemented procedures to formally identify employees whose compensation is at or near the Executive Level II cap and to monitor compensation charged to federal programs on an ongoing basis. Management will document these procedures, establish defined review thresholds, and require supervisory review of compensation allocations to ensure amounts in excess of the applicable cap are excluded from federal charges. Any unallowable amounts identified will be adjusted in a timely manner. Management expects these controls to be fully implemented for the current fiscal year.
Show full finding ▾Hide full finding ▴Finding Number: 2025 001 Finding Type: Immaterial noncompliance and significant deficiency in internal controls over compliance related to allowable costs Information on the Federal Program: Program Name: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) (ALN 93.224) Federal Awards Project Title: Health Center Program Award Period: June 1, 2024 – May 31, 2025 Award Number: H80CS00640 Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Criteria: Under 2 CFR §200.430(c)(2), compensation charged to federal awards must comply with the Executive Level II salary limitation established by the Office of Personnel Management (OPM). Salary costs allocated to the Health Center Program may not exceed this cap, and only the allowable portion up to the Executive Level II rate may be charged to the federal award. Condition: During testing of payroll allocated to the federal program, 1 of the 25 employees tested had salary charges which exceeded the Executive Level II compensation cap. Upon further review of the full population, a total of 3 employees were identified whose salary charges to the federal program exceeded the cap. Cause: The Organization relied on an informal, manual process to identify employees at or near the Executive Level II compensation cap. This process was not supported by documented policies, defined thresholds, or supervisory review controls. Effect: Unallowable salary amounts were initially charged to the grant. However, the Organization was able to identify other allowable expenditures sufficient to support the total amount of grant funds drawn. Questioned Costs: None Repeat Finding: No Recommendation: We recommend the Organization implement a formalized internal control process to monitor and enforce compliance with the Executive Level II compensation cap. This should include documented procedures for identifying employees subject to the cap, periodic monitoring of compensation charged to federal programs, and evidence of supervisory review to help ensure amounts in excess of the cap are excluded from allowable costs and appropriately allocated to nonfederal funding sources. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. The Organization has implemented procedures to formally identify employees whose compensation is at or near the Executive Level II cap and to monitor compensation charged to federal programs on an ongoing basis. Management will document these procedures, establish defined review thresholds, and require supervisory review of compensation allocations to ensure amounts in excess of the applicable cap are excluded from federal charges. Any unallowable amounts identified will be adjusted in a timely manner. Management expects these controls to be fully implemented for the current fiscal year.
Finding: 2025-001 Condition Found: During testing of payroll allocated to the federal program, 1 of the 25 employees tested had salary charges which exceeded the Executive Level II compensation cap. Upon further review of the full population, a total of 3 employees were identified whose salary charges to the federal program exceeded the cap. Individual(s) Responsible for Corrective Action: Elizabeth Clark, Director of Finance Planned Corrective Action: Upon review of the salary allocation template, we found that the individuals whose salaries exceeded the Executive Level II compensation cap were allocated to grants without the application of appropriate proration. The result was that excess amounts could have been applied to grants in error. To identify and correct these errors, we will look back 12 months at all salaries charged against any grant that is funded directly or indirectly by federal funds. If any salaries in excess of the Executive Level II compensation cap were charged, we will reverse that charge and substitute another qualifying employee salary in its place. The procedure for allocating salaries to grants will be modified to include instructions to exclude employees with salaries exceeding the cap from grant allocations. Anticipated Completion Date: February 15, 2026
FAC accepted this audit on January 30, 2025 — management decision was due July 30, 2025.
FAC accepted this audit on February 27, 2024 — management decision was due August 27, 2024.
In a sample of three of nine cash draw downs from PMS, each of the three transactions tested were drawn in a proportion in excess of the Federal Percentage Share as required by the terms and conditions of the award. Cause: The Organization experienced a transition in management positions during the year and did not thoroughly understand the specified terms and conditions of the award. Effect: The Organization may draw down funding in a proportion greater than is allowed and if the project does not get completed, it could result in the return of funds with potential interest. Questioned Costs: None Repeat Finding: No Recommendation: Management should provide additional training to individuals responsible for monitoring grant compliance, reinforce the importance of reviewing all grant agreement provisions, and implement a system of processes and controls for tracking compliance with all specific grant terms and conditions. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. The Organization will modify procedures as appropriate and provide additional training and education as recommended.
Show full finding ▾Hide full finding ▴Finding Type: Nonmaterial noncompliance related to cash management Information on the Federal Program: Program Name: Affordable Care Act (ACA) Grants for Capital Development in Health Centers (AL 93.526) Federal Awards Project Title: Health Center Infrastructure Support Award Period: September 15 2021- September 14, 2024 Award Number: 1 C8ECS43818-01 Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Criteria: According to the terms and conditions of the award, each budget has a Federal Percentage Share based upon the award amount and the total allowable costs. Grant funds can only be drawn down from the Payment Management System (PMS) as allowable costs are incurred. Unless otherwise authorized, draw down should be done in the same proportion as the grant is to total project costs in the approved budget. Condition: In a sample of three of nine cash draw downs from PMS, each of the three transactions tested were drawn in a proportion in excess of the Federal Percentage Share as required by the terms and conditions of the award. Cause: The Organization experienced a transition in management positions during the year and did not thoroughly understand the specified terms and conditions of the award. Effect: The Organization may draw down funding in a proportion greater than is allowed and if the project does not get completed, it could result in the return of funds with potential interest. Questioned Costs: None Repeat Finding: No Recommendation: Management should provide additional training to individuals responsible for monitoring grant compliance, reinforce the importance of reviewing all grant agreement provisions, and implement a system of processes and controls for tracking compliance with all specific grant terms and conditions. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. The Organization will modify procedures as appropriate and provide additional training and education as recommended.
Finding: 2023-001 Condition: In a sample of three of nine cash draw downs from PMS, each of the three transactions tested were drawn in a proportion in excess of the Federal Percentage Share as required by the terms and conditions of the award. Individual(s) Responsible for Corrective Action: Elidoro Primero, CFO Planned Corrective Action: Management will provide additional training to individuals for monitoring grant compliance, reinforcing the importance of grant provisions and implementing a system of processes and controls for tracking compliance with all specific grant terms and conditions. Management will also solicit guidance/best practice from designated HRSA grant management officer for voluntary correction action steps to resolve finding. Anticipated Completion Date: June 30, 2024
FAC accepted this audit on June 28, 2023 — management decision was due December 28, 2023.
FAC accepted this audit on February 9, 2022 — management decision was due August 9, 2022.
FAC accepted this audit on January 28, 2021 — management decision was due July 28, 2021.
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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