Jericho Road Ministries Inc. d/b/a Jericho Road Community Health CenterNon-Profit

Criteria or specific requirement: As a recipient of federal grant funds, the Center is expected to comply with procurement regulations applicable to federal grantees via an established written procurement policy, in accordance with Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Condition and context: The Center’s written Procurement Policy does not comply with the Uniform Guidance. Cause: The cause is due to a lack of understanding of the requirements outlined in the Uniform Guidance. Effect or potential effect: Without a policy in place that complies with the Uniform Guidance, the Center may not exhaust all efforts to award contract(s) under a process where maximum competition is achieved in order to obtain the most reasonable price. Identification as a repeat finding, if applicable: This is a repeat finding from the prior year. Recommendation: The Center should establish a written Procurement Policy that adheres to the Uniform Guidance requirements. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

Criteria or specific requirement: The Health Center Program (93.224) requires grantees to 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. Condition and context: Internal review processes were not completed for nine individuals that received the Sliding Fee Discount. Cause: There is limited review of entry into the internal database for eligibility. Effect or potential effect: Without adequate controls over this process, the Center may provide discounts to ineligible patients.Questioned costs: None.Identification as a repeat finding, if applicable: The Sliding Fee Discount process had a finding last year whereby two individuals who received the discount were not eligible. This was due to the lack of a review process. Recommendation: The Center should ensure that internal control processes for the Sliding Fee Discount policy are consistently followed. A review process should be in place for all patient information entered into the Center’s billing software. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

Criteria or specific requirement: As a recipient of federal grant funds, the Center is expected to comply with procurement regulations applicable to federal grantees via an established written procurement policy, in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Condition and context: The Center’s written Procurement Policy does not comply with the Uniform Guidance. Cause: The cause is due to a lack of understanding of the requirements outlined in the Uniform Guidance.Effect or potential effect: Without a policy in place that complies with the Uniform Guidance in place, the Center may not exhaust all efforts to award contract(s) under a process where maximum competition is achieved in order to obtain the most reasonable price.Identification as a repeat finding, if applicable: This is a repeat finding from the prior year. Recommendation: The Center should establish a written Procurement Policy that adheres to the Uniform Guidance requirements.Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

Criteria or specific requirement: As a recipient of federal grant funds, the Center is expected to comply with cash management regulations applicable to federal grantees via an established written drawdown policy, in accordance with Title 2 U.S. CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance.Condition and context: The Center did not have an established control process in place in relation to the drawdown of federal funds. Cause: The cause is due to staffing turnover experienced within the Center.Effect or potential effect: Without a policy in place that complies with the Uniform Guidance, the Center may draw down inaccurate or inappropriate federal funds. Recommendation: The Center should establish a written Drawdown Policy that adheres to the Uniform Guidance requirements, which includes a review by the CFO. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

Criteria or specific requirement: In accordance with 2 CFR 200.512, the Center is required to complete and submit the data collection form within the earlier of 30 days after receipt of the auditor’s report or nine months after the end of the audit period. Condition and context: The Center did not submit the single audit within the required period for submission.Cause: The Center did not have sufficient staffing in place to properly monitor and adhere to the respective due dates.Effect or potential effect: The Center did not comply with the requirements of 2 CFR 200.512.Identification as a repeat finding, if applicable: This is a repeat finding from the prior year. Recommendation: Staffing should be sufficient to ensure that all external reports are prepared and submitted on a timely basis. Staffing should contemplate not only the preparation of the various reports but also a formal, documented review process.Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

2023-003: Sliding Fee Discount Processes Criteria or specific requirement: The Health Center Program (93.224) requires grantees to prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: Two individuals that received the Sliding Fee Discount were not eligible based on income. Cause: This was due to a clerical error entered into the Center’s internal database. There is no review process of entry into the internal database for eligibility. Effect or potential effect: Without adequate controls over this process, the Center may provide discounts to ineligible patients. Recommendation: The Center should establish internal control processes for the Sliding Fee Discount policy as a whole. A review process should be in place for all patient information entered into the Center’s billing software. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

2023-004: Accurate and Complete Schedule of Expenditures of Federal Awards (SEFA) Criteria or specific requirement: The Center must prepare a SEFA that is accurate and complete in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Condition: The Center did not prepare a SEFA that was accurate and complete in accordance with the Uniform Guidance, as there were three programs missing from the original SEFA that was provided for audit. Cause: The cause is due to limited internal controls related to the preparation and review of the SEFA and the understanding of which items should be included. Effect or potential effect: Without adequate controls over this process, the Center may not identify all federal awards received and related compliance and reporting requirements applicable to each award. Recommendation: The Center must assign individuals who are experienced and knowledgeable in the compliance requirements of the Uniform Guidance to monitor all federal grants received to ensure that the Center has met the applicable compliance and reporting requirements of each federal award. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

2023-005: Established Written Procurement Policy Criteria or specific requirement: As a recipient of Federal grant funds, the Center is expected to comply with procurement regulations applicable to Federal grantees via an established written procurement policy, in accordance with Title 2 U.S. CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Condition: The Center’s written Procurement Policy does not comply with Uniform Guidance. Cause: The cause is due to a lack of understanding of requirements outlined by the Uniform Guidance. Effect or potential effect: Without a policy in place that complies with Uniform Guidance in place, the Center may not exhaust all efforts to award contract(s) under a process where maximum competition is achieved in order to obtain the most reasonable price. Recommendation: The Center should establish a written Procurement Policy that adheres to Uniform Guidance requirements. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

2023-006: External Financial Reporting Criteria or specific requirement: The Health Center Program (93.224) requires financial reports to be submitted within prescribed deadlines. Condition: One Federal Financial Report (SF-425) was submitted to the U.S. Department of Health and Human Services after prescribed deadlines. Cause: The Center does not have adequate staffing in place to monitor and adhere to each respective due date. Effect or potential effect: Without proper staffing, the Center could experience ramifications for the lack of timely reporting. Recommendation: The Center must assign individuals who are experienced and knowledgeable in the compliance requirements of the Uniform Guidance to monitor all federal grants received to ensure that the Center has met the applicable compliance and reporting requirements of each federal award. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

2023-007: Single Audit Report Submission Criteria or specific requirement: In accordance with 2 CFR 200.512, the Center was required to complete and submit the data collection form within the earlier of 30 days after receipt of the auditor’s report or nine months after the end of the audit period. Condition: The Center did not submit the single audit within the required period for submission. Cause: The Center did not have sufficient staffing in place to properly monitor and adhere to the respective due dates. Effect or potential effect: The Center did not comply with the requirements of 2 CFR 200.512. Recommendation: Staffing should be sufficient to ensure that all external reports are prepared and submitted on a timely basis. Staffing should contemplate not only the preparation of the various reports, but also a formal, documented review process. Views of responsible officials: Refer to the Corrective Action Plan prepared by the Center in regard to this matter.

GSA_MIGRATION