EIN: 391760445
UEI: W26RFPQL4FL6
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 30, 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 September 30, 2026 (33 days from today).
What is a management decision? →During the testing of expenses charged to the grant, it was noted that the same expense was charged to the grant as part of two separate grant draws. Questioned Costs: $7,629. Context: The above condition impacted one (1) of sixty (60) transactions selected for testing. However, subsequent to year end and prior to the close of the grant period, the Organization identified the overdraw and corrected the error by reducing amounts requested in a subsequent draw. Cause: The Organization had inconsistent methods for tracking general disbursements charged to the grant and did not implement procedures to verify whether expenditures had already been included in prior draw requests. Effect: The Organization may inadvertently overcharge the grant for general disbursements which could result in noncompliance with federal grant requirements. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all payroll and non-payroll expenses charged to the grant prior to submitting the drawdown request to HRSA and implement a consistent process for identifying the specific expenses being charged to each grant.
Show full finding ▾Hide full finding ▴Allowable Activities and Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Cluster - Behavioral Health Expansion Grant Assistance Listing Number: 93.224 and 93.527 Federal Award Identification Number: H8NCS54238-01-00 Award Periods: September 1, 2024 – August 31, 2025 Type of Finding: Immaterial noncompliance and significant deficiency in internal control over compliance Criteria: A grantee's system of internal control should include processes to review after-the-fact interim charges made to a federal award based on budget estimates. 45 CFR 75.430(i)(1). Condition: During the testing of expenses charged to the grant, it was noted that the same expense was charged to the grant as part of two separate grant draws. Questioned Costs: $7,629. Context: The above condition impacted one (1) of sixty (60) transactions selected for testing. However, subsequent to year end and prior to the close of the grant period, the Organization identified the overdraw and corrected the error by reducing amounts requested in a subsequent draw. Cause: The Organization had inconsistent methods for tracking general disbursements charged to the grant and did not implement procedures to verify whether expenditures had already been included in prior draw requests. Effect: The Organization may inadvertently overcharge the grant for general disbursements which could result in noncompliance with federal grant requirements. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all payroll and non-payroll expenses charged to the grant prior to submitting the drawdown request to HRSA and implement a consistent process for identifying the specific expenses being charged to each grant.
Allowable Activities and Costs Allowable Activities and Costs Health Center Cluster - Behavioral Health Expansion – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all payroll and non-payroll expenses charged to the grant prior to submitting the drawdown request to HRSA and implement a consistent process for identifying the specific expenses being charged to each grant in order to avoid a cost being allocated more than one. Action taken in response to finding: The process has been changed as of August 1, 2025 before the end of the grant period of performance and will continue forward. Name(s) of the contact person(s) responsible for corrective action: John Robinson, CFO Planned completion date for corrective action plan: August 1, 2025
We noted the Organization did not have a formal process to review expenditures charged to federal programs to ensure they were incurred within the applicable period of performance. Specifically, management did not maintain documentation or a monitoring process to verify that expenditures recorded near the beginning or end of the grant period were incurred within the authorized period of performance. Questioned Costs: $6,504 Context: Seven (7) and of the eleven (11) transactions selected for testing related to expenditures incurred outside the period or performance. Cause: The Organization did not have a formal policy and procedure to closely review the expense charged to the grant during the first and last months of the grant period. Effect: Without adequate controls over period of performance, there is an increased risk that expenditures could be charged to federal awards outside the approved grant period. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review and monitor expenditures charged near the beginning and end of grant periods to ensure the expenditures incurred are within the authorized federal award grant period.
Show full finding ▾Hide full finding ▴Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Centers Cluster Assistance Listing Number: 93.224 and 93.527 Federal Award Identification Number: H80CS00824-24 Award Periods: May 1, 2025 – April 30, 2026 Type of Finding: Immaterial noncompliance and significant deficiency in internal control over compliance Criteria: Per 2 CFR 200.309, federal award recipients may charge to the federal award only allowable costs incurred during the approved period of performance. The auditee is responsible for establishing and maintaining effective internal control procedures to ensure expenditures charged to federal programs are incurred within the approved grant period. Condition: We noted the Organization did not have a formal process to review expenditures charged to federal programs to ensure they were incurred within the applicable period of performance. Specifically, management did not maintain documentation or a monitoring process to verify that expenditures recorded near the beginning or end of the grant period were incurred within the authorized period of performance. Questioned Costs: $6,504 Context: Seven (7) and of the eleven (11) transactions selected for testing related to expenditures incurred outside the period or performance. Cause: The Organization did not have a formal policy and procedure to closely review the expense charged to the grant during the first and last months of the grant period. Effect: Without adequate controls over period of performance, there is an increased risk that expenditures could be charged to federal awards outside the approved grant period. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review and monitor expenditures charged near the beginning and end of grant periods to ensure the expenditures incurred are within the authorized federal award grant period.
Period of Performance Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review and monitor expenditures charged near the beginning and end of grant periods to ensure the expenditures incurred are within the authorized federal award grant period. Action taken in response to finding: A procedure was implemented March 2026 to perform an internal audit of the expenditures charged within the pre-and-post 30 days of a grant year transition to ensure expenses are occurring within the appropriate grant year prior to draw submission and will continue moving forward. A remedy of $87,554.96 was implemented over two grant draws within the grant year to address the population of period of performance crossing expenses. Name(s) of the contact person(s) responsible for corrective action: John Robinson, CFO Planned completion date for corrective action plan: New policy and procedure implemented in March 2026 and will be carried forward.
During our audit procedures, we noted the Organization did not have adequate internal controls related to maintaining supporting documentation for all of the key tables included within the UDS report. Questioned Costs: None. Context: The Organization submitted its annual UDS report, which includes multiple data tables derived from various systems and sources, including billing, electronic health records, and financial records. During our testing, the Organization was not able to provide the necessary documentation to support the amounts reported in Table 8A Lines 1 & 3. Cause: The condition appears to be due to turnover within the finance department and not maintaining the necessary supporting documentation used to prepare the UDS report as filed. Effect: Without adequate controls over reporting, there is an increased risk that reports submitted to the federal awarding agency may be inaccurate or incomplete, which could impact funding, compliance, and federal oversight. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review reports prior to submission including the reconciliations and underlying records that support the amounts in the report.
Show full finding ▾Hide full finding ▴Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Centers Cluster Assistance Listing Number: 93.224 and 93.527 Federal Award Identification Number: H80CS00824-23-11 Award Periods: May 1, 2024 – April 30, 2025 Type of Finding: Significant deficiency in internal control over compliance Criteria: The Organization is required to submit an annual Uniform Data System (UDS) report to HRSA that is complete, accurate, and supported by underlying records. Per federal requirements, the auditee is responsible for establishing and maintaining effective internal controls over compliance, including controls to ensure the accuracy and completeness of reports submitted to federal agencies. Condition: During our audit procedures, we noted the Organization did not have adequate internal controls related to maintaining supporting documentation for all of the key tables included within the UDS report. Questioned Costs: None. Context: The Organization submitted its annual UDS report, which includes multiple data tables derived from various systems and sources, including billing, electronic health records, and financial records. During our testing, the Organization was not able to provide the necessary documentation to support the amounts reported in Table 8A Lines 1 & 3. Cause: The condition appears to be due to turnover within the finance department and not maintaining the necessary supporting documentation used to prepare the UDS report as filed. Effect: Without adequate controls over reporting, there is an increased risk that reports submitted to the federal awarding agency may be inaccurate or incomplete, which could impact funding, compliance, and federal oversight. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review reports prior to submission including the reconciliations and underlying records that support the amounts in the report.
Reporting Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review reports prior to submission including the reconciliations and underlying records that support the amounts in the report. Action taken in response to finding: An internal audit and review of the UDS reporting supporting files will be implemented as of April 1, 2026 to ensure accuracy of the documentation and calculations. Name(s) of the contact person(s) responsible for corrective action: John Robinson, CFO Planned completion date for corrective action plan: April 1, 2026 and it will continue moving forward.
FAC accepted this audit on March 31, 2025 — management decision was due October 1, 2025.
During the testing of payroll expenses charged to the grant, it was noted that a formula error resulted in the incorrect calculation of payroll expense for a particular employee. The Organization’s review did not identify that the wages being charged to the grant were inconsistent with the amount actually paid to the identified employee. Questioned Costs: $757. Context: The above condition impacted three (3) of sixty (60) transactions selected for testing, all of which related to the same employee. Cause: The Organization’s process for tracking and aggregating wages charged to the grant was dependent upon a VLOOKUP formula based on the employee’s last name. As a result of there being two employees with the same last name, the formula returned the first such employee from the payroll records. This resulted in the incorrect calculation of payroll expense for the employee selected for testing. Effect: The amount of wages charges to the grant could be different from the actual amount of wages paid to the employee. Repeat Finding: Yes. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all wages charged to federal and state grant prior to initiating a drawdown request or submitting a reimbursement request to the grantor. As part of this, the Organization should implement a process to review changes to salary and wage information as changes are made or identified.
Show full finding ▾Hide full finding ▴Allowable Activities and Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Centers Cluster Assistance Listing Number: 93.224 and 93.527 Federal Award Identification Number: H80CS00824-22 and H80CS00824-23 Award Periods: May 1, 2023 – April 30, 2024, May 1, 2024 – April 30, 2025 Type of Finding: Immaterial noncompliance and significant deficiency in internal control over compliance Criteria: A grantee's system of internal control should include processes to review after-the-fact interim charges made to a federal award based on budget estimates. 45 CFR 75.430(i)(1). In addition, CFR 200.430 indicates costs of compensation are allowable to the extent that they satisfy the specific requirement of determining and supporting the salary and wages based on records that accurately reflect the work performed. Salaries and wages charged to a grant should be tagged/identified by employee to ensure expenses are not counted or charged twice. Condition: During the testing of payroll expenses charged to the grant, it was noted that a formula error resulted in the incorrect calculation of payroll expense for a particular employee. The Organization’s review did not identify that the wages being charged to the grant were inconsistent with the amount actually paid to the identified employee. Questioned Costs: $757. Context: The above condition impacted three (3) of sixty (60) transactions selected for testing, all of which related to the same employee. Cause: The Organization’s process for tracking and aggregating wages charged to the grant was dependent upon a VLOOKUP formula based on the employee’s last name. As a result of there being two employees with the same last name, the formula returned the first such employee from the payroll records. This resulted in the incorrect calculation of payroll expense for the employee selected for testing. Effect: The amount of wages charges to the grant could be different from the actual amount of wages paid to the employee. Repeat Finding: Yes. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all wages charged to federal and state grant prior to initiating a drawdown request or submitting a reimbursement request to the grantor. As part of this, the Organization should implement a process to review changes to salary and wage information as changes are made or identified.
Allowable Activities and Costs Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all wages charged to federal and state grant prior to initiating a drawdown request or submitting a reimbursement request to the grantor. As part of this, the Organization should implement a process to review changes to salary and wage information as changes are made or identified.. Action taken in response to finding: The process has been changed as of July 1, 2024 and will continue forward. Name(s) of the contact person(s) responsible for corrective action: Daria Sztaba, CFO Planned completion date for corrective action plan: July 1, 2024
2023-002
The Organization did not assign patients properly to a sliding fee category in their system based on the Organization’s sliding fee scale policy. Information entered into the system did not match the information gathered from patients at the time of the encounter. Questioned Costs: None. Context: Four (4) of forty (40) encounters were not assigned the correct sliding fee category based on the current documentation of family size and income to assess sliding fee discount eligibility. Cause: The information entered into the Organization’s system was not reviewed to verify the proper sliding fee scale was applied for the services performed based on the information gathered from the patient. Effect: Patients may not be assessed a correct sliding fee discount according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all patient information received, prior to it being entered into the system to ensure proper classification of the sliding fee scale. As part of this, the Organization should ensure the accuracy and completeness of the patient information prior to entering into the billing software. Management should work to conduct internal audits of patient visits to determine all required patient information has been obtained and properly entered into the system in accordance with the Organization’s sliding fee scale policy.
Show full finding ▾Hide full finding ▴Special Provisions Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Centers Cluster and Health Center Infrastructure Support Assistance Listing Number: 93.224 and 93.527 Federal Award Identification Number: H80CS00824-22 and H80CS00824-23 Award Periods: May 1, 2023 – April 30, 2024, May 1, 2024 – April 30, 2025 Type of Finding: Immaterial noncompliance and material weakness in internal control over compliance Criteria: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Condition: The Organization did not assign patients properly to a sliding fee category in their system based on the Organization’s sliding fee scale policy. Information entered into the system did not match the information gathered from patients at the time of the encounter. Questioned Costs: None. Context: Four (4) of forty (40) encounters were not assigned the correct sliding fee category based on the current documentation of family size and income to assess sliding fee discount eligibility. Cause: The information entered into the Organization’s system was not reviewed to verify the proper sliding fee scale was applied for the services performed based on the information gathered from the patient. Effect: Patients may not be assessed a correct sliding fee discount according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all patient information received, prior to it being entered into the system to ensure proper classification of the sliding fee scale. As part of this, the Organization should ensure the accuracy and completeness of the patient information prior to entering into the billing software. Management should work to conduct internal audits of patient visits to determine all required patient information has been obtained and properly entered into the system in accordance with the Organization’s sliding fee scale policy.
Special Tests and Provisions Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all patient information received, prior to it being entered into the system to ensure proper classification of the sliding fee scale. As part of this, the Organization should ensure the accuracy and completeness of the patient information prior to entering into the billing software. Management should work to conduct internal audits of patient visits to determine all required patient information has been obtained and properly entered into the system in accordance with the Organization’s sliding fee scale policy. Action taken in response to finding: A monthly internal audit of the sliding fee (HNP) will be implemented and as of April 1, 2025 to ensure accuracy of the documentation and calculations. Name(s) of the contact person(s) responsible for corrective action: Daria Sztaba, CFO Planned completion date for corrective action plan: April 1, 2025 and it will continue moving forward on a monthly basis.
FAC accepted this audit on March 27, 2024 — management decision was due September 27, 2024.
The Organization did not verify that the wages being charged to the grant were consistent with the amount paid to employees. The internal controls over compliance were not properly set up to identify this until the audit testing was complete. In addition, the organization had inconsistent methods of tracking wages being charged to federal grants. Records were not kept consistently to support how employee wages were identified prior to drawdowns being submitted. Questioned Costs: As a result of our audit procedures, we identified questioned costs in the amount of $977 related to the Organization charging wages in excess of the amount actually paid to the employee. Context: One (1) of forty (40) transactions Cause: The organization had inconsistent methods of tracking salaries and wages charged to the grant and did not verify that the wages charged to the grant matched what was incurred by the Organization and paid to the employee. Effect: The Organization may inadvertently over charge the grant for wages that were not incurred or paid to employees. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all wages charged to federal and state grant prior to initiating a drawdown request or submitting a reimbursement request to the grantor. As part of this, the Organization should implement a consistent process for identifying the specific employees and wages being charged to each grant.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Centers Cluster Assistance Listing Number: 93.224 and 93.527 Federal Award Identification Number: H80CS00824-21-00; H80CS00824-22-00; H8FCS41534-01-02 Award Periods: May 1, 2022 – April 30, 2023; May 1, 2023 – April 30, 2024; April 1, 2021 – March 31, 2023, respectively Type of Finding: Compliance and material weakness in internal control over compliance Criteria: A grantee's system of internal control should include processes to review after-the-fact interim charges made to a Federal award based on budget estimates. 45 CFR 75.430(i)(1). In addition, CFR 200.430 indicates costs of compensation are allowable to the extent that they satisfy the specific requirement of determining and supporting the salary and wages based on records that accurately reflect the work performed. Salaries and wages charged to a grant should be tagged/identified by employee to ensure expenses are not counted or charged twice. Condition: The Organization did not verify that the wages being charged to the grant were consistent with the amount paid to employees. The internal controls over compliance were not properly set up to identify this until the audit testing was complete. In addition, the organization had inconsistent methods of tracking wages being charged to federal grants. Records were not kept consistently to support how employee wages were identified prior to drawdowns being submitted. Questioned Costs: As a result of our audit procedures, we identified questioned costs in the amount of $977 related to the Organization charging wages in excess of the amount actually paid to the employee. Context: One (1) of forty (40) transactions Cause: The organization had inconsistent methods of tracking salaries and wages charged to the grant and did not verify that the wages charged to the grant matched what was incurred by the Organization and paid to the employee. Effect: The Organization may inadvertently over charge the grant for wages that were not incurred or paid to employees. Repeat Finding: No. Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all wages charged to federal and state grant prior to initiating a drawdown request or submitting a reimbursement request to the grantor. As part of this, the Organization should implement a consistent process for identifying the specific employees and wages being charged to each grant.
Action taken in response to finding: A comprehensive spreadsheet including all wages allocated to Federal Grants was created during the course of the Federal Awards program Audits. This spreadsheet allows SBCHC staff to track and verify all wages allocated to Federal Awards on a contemporary basis with internal checks and balances included. These verification processes now happen with every payroll cycle and are documented as such. Any revisions that are required now occur on a regular basis and correspond with the bi-weekly payroll cycle. Name(s) of the contact person(s) responsible for corrective action: Matt Gehri, CFO Planned completion date for corrective action plan: Currently deployed as of February 2024, and has been reviewed back to the beginning of the H80 Federal Grant year of May 1, 2023.
For a portion of the year under audit, the Organization did not have a procurement policy that complied with 2 CFR 200.320 and did not maintain sufficient documentation to support the use of an approved or prequalified vendor listing. As a result of this, the Organization incorrectly applied the micro-purchase methodology to transactions which qualified for the simplified acquisition method. Questioned Costs: Unknown. Context: Five (5) of five (5) transactions selected for procurement testing. Cause: The Organization did not have a procurement policy which was consistent with 2 CFR 200.230 during a specific period of time during the year under audit. During the last quarter of the fiscal year, the Organization did update its procurement policy to be consistent with the requirements of the Uniform Guidance. Effect: Without an appropriate procurement policy, there is a potential to use federal grants in a manner which is not the most efficient and economical. Repeat Finding: No.
Show full finding ▾Hide full finding ▴Finding 2023-003 – Procurement Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Centers Cluster and Health Center Infrastructure Support Assistance Listing Number: 93.224, 93.527 and 93.526 Federal Award Identification Number: H80CS00824-21-00; H80CS00824-22-00; H8FCS41534-01-02; C8EC44826-01-00 Award Periods: May 1, 2022 – April 30, 2023; May 1, 2023 – April 30, 2024; April 1, 2021– March 31, 2023; September 15, 2021 – September 15, 2024, respectively Type of Finding: Compliance and material weakness in internal control over compliance Criteria: 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 (2 CFR 200.318). Additionally, the non-federal entity must have and use documented procurement procedures, consistent with the standards of 2 CFR 200.320 which includes five acceptable methods of procurement which vary based on the size of the purchase and nature of the expense. Condition: For a portion of the year under audit, the Organization did not have a procurement policy that complied with 2 CFR 200.320 and did not maintain sufficient documentation to support the use of an approved or prequalified vendor listing. As a result of this, the Organization incorrectly applied the micro-purchase methodology to transactions which qualified for the simplified acquisition method. Questioned Costs: Unknown. Context: Five (5) of five (5) transactions selected for procurement testing. Cause: The Organization did not have a procurement policy which was consistent with 2 CFR 200.230 during a specific period of time during the year under audit. During the last quarter of the fiscal year, the Organization did update its procurement policy to be consistent with the requirements of the Uniform Guidance. Effect: Without an appropriate procurement policy, there is a potential to use federal grants in a manner which is not the most efficient and economical. Repeat Finding: No.
Action taken in response to finding: As referenced in the Audit report, a comprehensive new Procurement procedure that is fully compliant with Uniform Guidance was implemented in April 2023 and has been in place and utilized since then. In addition, a preferred Vendor list will be generated by May 31st, 2024. This list will also be reviewed and updated at least on an annual basis, with interim revisions being done as needed. Name(s) of the contact person(s) responsible for corrective action: Matt Gehri, CFO Planned completion date for corrective action plan: April 2023 for new Procurement procedure, and May 31st, 2024 for Preferred Vendor list.
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