EIN: 411386986
UEI: T3LVDJQMMWA1
Data as of August 20, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 14, 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 December 14, 2024, which was (615 days ago).
What is a management decision? →Monitoring of Grant Expenditures Criteria or Specific Requirement: An organizations internal control processes should provide for the accurate reporting of grant expenditures and timely identification of any unallowable costs that could be charged to grants in error. Condition: Subsequent to December 31, 2023, management identified $134,837 of costs that were charged to federal grants in error for the year ended December 31, 2023. After the error was identified, the Organization consulted the respective grant funding sources and came to agreement with substantially all of the funding sources to substitute the unallowable costs with other allowable costs either from 2023 or 2024. No costs are questioned since the questioned costs were removed prior to issuance of the consolidated financial statements. Questioned Costs: No costs were questioned since substantially all unallowable costs were removed from federal grant expenditures. Context: In planning and performing our audit procedures, we obtained an understanding of the design and implementation of internal controls for significant audit risk and performed audit procedures assessing the effectiveness of internal controls. Additionally, we performed substantive audit procedures to obtain audit evidence verifying the completeness, validity, and accuracy of the financial records. Effect: A significant deficiency in internal control over financial reporting exist due to untimely identification of certain unallowable costs for some select grants. Cause: The Organization's procedures did not identify the unallowable grant costs at the point of expenditure and the subsequent detective controls were not timely. Repeat: No Auditor's Recommendations: Organization management should ensure policies are consistently followed for unallowable grant costs for every grant award so that they are identified at the point of initial grant billing. View of Responsible Officials: Upon Management detecting that select grants were charged a specific cost, immediate action was taken to identify the scope of the matter and remedy the matter with the effected granting agencies. The granting agencies understood the situation and supported our immediate response solutions.
Management Response: CLUES’ financial management detected an oversight in billing a specific unallowable cost to certain grants that fund our Behavioral Health (“BH”) clinics. The oversight was promptly investigated, and we immediately remedied the situation with the affected funders. CLUES has taken action to prevent similar potential errors in the future. Two of our grants account for the majority of the improper billing total. The funders agreed that we can charge other billable expenses not previously covered. CLUES expended all funds with the funder’s approval. This matter was resolved and reported to the funder’s satisfaction. Action taken in response to finding: Management immediately identified the scope of the billing discrepancy, contacted the funders to resolve it, and have incorporated training and monitoring procedures internally to ensure we do not inadvertently bill such unallowable costs again. Proper review processes have been implemented to detect and prevent similar findings in the future. Name of the contact person responsible for corrective action: Ryan Robinson (VP of Finance & Administration) Planned completion date for corrective action plan: This matter was resolved in May 2024.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on February 12, 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 12, 2024, which was (739 days ago).
What is a management decision? →2022-003: Suspension & Debarment Federal agency: Department of Health and Human Services Federal program: Substance Abuse and Mental Health Services Administration (SAMHSA) – Health Clinic (CCBHC) Expansion Assistance Listing Numbers: 93.829 Federal Award Identification Number and Year: 5H79SM085197-02 Award Period: January 1, 2022 – December 31, 2022 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Compliance - Other Matter Criteria or specific requirement: When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at https://www.beta.sam.gov, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). In addition, 2 CFR 200.303 in the federal regulations cover internal controls over compliance. Condition: We identified two of the four vendors sampled that lacked documentation supporting the vendor was not suspended or debarred prior to entering into a covered transaction. Questioned costs: None Context: Of the four covered transactions tested, two lacked documentation supporting the Organization verified the vendor was not suspended or debarred prior to entering into a covered transaction. Cause: Management did not retain evidence demonstrating they verified the vendors were not suspended or debarred prior to entering into the covered transaction. Effect: By not retaining evidence that management verified vendors were not suspended or debarred, management may erroneously enter into a covered transaction with vendors that were suspended or debarred. Repeat finding: No Recommendation: We recommend management adopt a policy to ensure evidence of compliance to suspension and debarment regulations are maintained. This can include maintaining evidence that management reviewed the GSA website, maintaining a certification from the vendor, or including a clause in a contract with vendors that they are not suspended or debarred. Views of responsible officials: Management did request and receive pre-approval from the federal granting agency to use the two specified vendors, but agree that we did not also retain explicit suspension and debarment documentation of those vendors at that time. We did subsequently verify they were not suspended or debarred.
Significant Deficiency 2023-003 Control over Compliance – Suspension & Debarment Documentation Assistance Listing No. 93.829– Substance Abuse and Mental Health Services Administration (SAMHSA)– Health Clinic(CCBHC) Expansion Recommendation: We recommend management adopt a policy to ensure evidence of compliance to suspension and debarment regulations are maintained. This can include maintaining evidence that management reviewed the GSA website, maintaining a certification from the vendor, or including a clause in a contract with vendors that they are not suspended or debarred. Management Response: Management requested and received pre-approval from the federal granting agency to use the two specified vendors identified in the audit finding. The two vendors are a reputable research nonprofit (and sole source for this work in Minnesota) and a reputable company used before to maintain our Electronic Health Records system. We could not show documentation of verifying the vendor’s suspension and debarment credentials prior to entering into the contract, so the auditors determined that they must report this matter since the control over reviewing the vendors’ suspension and debarment qualifications was not documented prior to signing a contract with them. We have met internally to ensure our procurement procedures account retain such documentation going forward, but Management reiterates that the federal granting agency approved the use of these vendors prior to entering into contract. Action taken in response to finding: Management received notification of this matter in June 2023 and conducted suspension and debarred verification. Upon notification of this matter, the VP of Finance and Administration and the Controller initiated improved processes and guidelines with the leads of our Procurement and Accounting teams to ensure documentation of suspension & debarment qualifications of current and future vendors/consultants for our programs and clinical services. In addition, our template contract for external services has been updated to require this verification prior to entering into a contract with external consultants/vendors so we can ensure compliance with this federal requirement. Name of the contact person responsible for corrective action: Ryan Robinson (VPFA) Planned completion date for corrective action plan: June 2023
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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