EIN: 273033445
UEI: NZCCA72AXLK1
Data as of August 19, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 8, 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 April 8, 2025, which was (499 days ago).
What is a management decision? →Finding: 2024-002 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. - 93.224 and 93.527 Federal Communications Commission COVID-19 Telehealth Program Assistance Listing No. – 32.006 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were performed as required. Effect: The Organization did not verify that vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that vendors are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Alice Salthouse, CEO Anticipated Date of Completion: October 31, 2024
In Finding 2024-002, a condition was noted in which the Organization did not verify that vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2024-002, procedures will be implemented to ensure debarment searches are completed and properly documented.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 23, 2022. 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 April 23, 2023, which was (1215 days ago).
What is a management decision? →Finding: 2022-002 Uniform Data System Report Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the year ended December 31, 2021, contained incorrect data for patient revenue. The charges and payments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $2.4 million. Cause: The above exception resulted from omitting 340B contract pharmacy charges in Table 9D of the Uniform Data System report. Effect: The DHHS reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that a system should be developed to ensure actual charges and payments from all sources including 340B contract pharmacies are reported and reconciled to the UDS report. The DHHS should be informed of the error and the 2021Table 9D should be revised and resubmitted if requested. Views of Responsible Officials: Management concurs. Efforts will be made to ensure that the revenue and expenses from all sources are reconciled to the revenue and expenses on the UDS report. Contact Person: Alice Salthouse, CEO Anticipated Date of Completion: October 31, 2022
In Finding 2022-002, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2021 contained incorrect data for patient revenue. The charges and payments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $2.4 million. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2022-002, efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. This will be implemented by the Chief Executive Officer by October 31, 2022.
2021-005
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on August 31, 2021. 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 March 3, 2022, which was (1631 days ago).
What is a management decision? →Finding: 2021-002 Cash Management ? Federal Grants Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Cash Management, 45 CFR 75.305 Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization?s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures. Cause: Failure to follow established policies and procedures regarding grant draws and ensuring draws do not exceed the authorized expenditures paid. Effect: Federal funds could be drawn in excess of expenditures. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures. Views of Responsible Officials: Management concurs. Management will reconcile all grant draws to the qualifying expenditures prior to making the draw request. Contact Person: Alice Salthouse, CEO Anticipated Date of Completion: October 31, 2021
In Finding 2021-002, a condition was noted in which the Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization?s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures. Management recognizes the importance of complying with federal grant draw guidelines. In response to Finding 2021-002, Management will reconcile all grant draws to the qualifying expenditures prior to making the draw request. This review will be performed by the Chief Executive Officer and completed by October 31, 2021.
Finding: 2021-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not ensure that quotes or bids were obtained in accordance with Organization policies. In addition, Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure that quotes or bids were obtained in accordance with Organization policies, and the Organization did not follow its policy regarding debarment searches. Effect: The Organization did not obtain quotes or bids for certain procurement transactions in accordance with Organization policies. In addition, the Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that the Organization implement procedures to ensure that quotes or bids are obtained and debarment searches are conducted in accordance with the Organization?s policies. Views of Responsible Officials: Management concurs. Procedures will be implemented to ensure that quotes or bids are obtained in accordance with previously established policies. The Organization will also establish procedures to ensure that debarment searches are completed to verify that all employees subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. Contact Person: Alice Salthouse, CEO Anticipated Date of Completion: October 31, 2021
In Finding 2021-003, a condition was noted that the Organization did not ensure that quotes or bids were obtained in accordance with Organization policies. In addition, Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2021-003, procedures will be implemented to ensure that quotes or bids are obtained in accordance with previously established policies. The Organization will also establish procedures to ensure that debarment searches are completed to verify that all employees subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. This review will be performed by the Chief Executive Officer and completed by October 31, 2021.
Finding: 2021-004-Board Member Compliance Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Policy Information Notice 2014-01 Condition: A majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should ?utilize the health center as their principal source of primary health care? in order for them to give substantive input into the Organization?s strategic direction and policy. Cause: The above exception resulted from the failure to follow established procedures requiring board members or their immediate families to be active users of the health center. Effect: This non-compliance with federal grant requirements could result in a reduction of grant funds or additional grant restrictions. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that procedures be established to ensure that more than fifty percent of board members are active users of the health center. Views of Responsible Officials: Management concurs with the audit finding. Procedures will be established to ensure that more than 50 percent of the board members are users of the health center. Contact Person: Alice Salthouse, CEO Anticipated Date of Completion: October 31, 2021
In Finding 2021-004, a condition was noted that a majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should ?utilize the health center as their principal source of primary health care? in order for them to give substantive input into the Organization?s strategic direction and policy. Management recognizes the importance of complying with board member compliance guidelines. In response to Finding 2021-004, procedures will be established to ensure that more than 50 percent of the board members are users of the health center. This review will be performed by the Chief Executive Officer and completed by October 31, 2021.
Finding: 2021-005 Uniform Data System Report Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Condition: The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the year ended December 31, 2020 contained incorrect data for patient revenue. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $1.6 million, and adjustments were understated by approximately $1.5 million. Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Cause: The above exception resulted from errors in preparing Table 9D of the Uniform Data System report. Effect: The DHHS reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that a system should be developed to ensure actual charges and adjustments from all sources are reported and reconciled to the UDS report. The DHHS should be informed of the error and the 2020 Table 9D should be revised and resubmitted if requested. Views of Responsible Officials: Management concurs. Efforts will be made to ensure that the revenue and expenses from all sources are reconciled to the revenue and expenses on the UDS report. Contact Person: Alice Salthouse, CEO Anticipated Date of Completion: October 31, 2021
In Finding 2021-005, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2020 contained incorrect data for patient revenue. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $1.6 million, and adjustments were understated by approximately $1.5 million. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2021-005, efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. This will be implemented by the Chief Executive Officer by October 31, 2021.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 12, 2018. 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 March 12, 2019, which was (2718 days ago).
What is a management decision? →Management decision deadline — for entities that funded this organization
The FAC accepted this audit on August 28, 2017. 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 February 28, 2018, which was (3095 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 13, 2016. 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 March 13, 2017, which was (3447 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
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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