EIN: 432016287
UEI: MK63LY924YQ3
Audited by: CLIFTONLARSONALLEN LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 31, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 17, 2025. 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 17, 2026 (137 days ago).
What is a management decision? →The Organization did not have a procurement policy or suspension and debarment policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization did not maintain appropriate documentation to support the procurement method utilized for contracts selected for testing. Questioned costs: None. Context: Eight (8) of eight (8) procurement transactions selected for testing. Cause: The Organization did not create and maintain appropriate documentation to support the method of procurement utilized. Effect: Possible noncompliance with 2 CFR section 200.320(c)(1) - (3). Repeat finding: No. Recommendation: We recommend the Organization revise its procurement and suspension and debarment policies to be consistent with the Uniform Guidance and consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Cluster Assistance Listing Number: 93.224/93.527 Federal Award Identification Number: H80CS12856 Award Periods: March 1, 2023 – February 29, 2024 Type of Finding: Material Weakness in Internal Control Over Compliance Criteria: 2 CFR section 200.320 outlines the acceptable methods of procurement. Purchases below the simplified acquisition threshold, but above the micro-purchase threshold, require that price or rate quotations be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. Noncompetitive procurement can be used in certain circumstances however the non-Federal entity is to maintain appropriate supporting documentation justifying the use of sole source procurement consistent with 2 CFR 200.320(c). Condition: The Organization did not have a procurement policy or suspension and debarment policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization did not maintain appropriate documentation to support the procurement method utilized for contracts selected for testing. Questioned costs: None. Context: Eight (8) of eight (8) procurement transactions selected for testing. Cause: The Organization did not create and maintain appropriate documentation to support the method of procurement utilized. Effect: Possible noncompliance with 2 CFR section 200.320(c)(1) - (3). Repeat finding: No. Recommendation: We recommend the Organization revise its procurement and suspension and debarment policies to be consistent with the Uniform Guidance and consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. Views of responsible officials: There is no disagreement with the audit finding.
Procurement Recommendation: The auditor recommends the Organization revise its procurement and suspension and debarment policies to be consistent with the Uniform Guidance and consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Consulting with TACHC to develop policies to be approved by the organization’s Board of Directors, and implement procedures to meet the suspension and debarment requirement Name(s) of the contact person(s) responsible for corrective action: David Rodrigues. Planned completion date for corrective action plan: December 2025.
As a result of the lack of a suspension and debarment policy, the organization did not document that Sam.gov was checked prior to entering into a contract with a vendor. Questioned costs: None. Context: Five (5) of five (5) vendors selected for testing did not have evidence prior to contracting of a check for suspension and debarment. However, subsequent review showed evidence the vendors were not suspended and debarred. Cause: Employee turnover. Effect: Possible noncompliance with 2 CFR section 200.320(c)(1) - (3). Repeat finding: No. Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. The organization can keep screenshots that Sam.gov was checked or a PDF print out of the web page which includes the date verified. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Cluster Assistance Listing Number: 93.224/93.527 Federal Award Identification Number: H80CS12856 Award Periods: March 1, 2023 – February 29, 2024 Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: 2 CFR sections 200.212 and 200.318(h); 2 CFR section 180.300; 48 CFR section 52.209-6 outlines that the non-Federal entity must verify that the agency in which it is entering into a contract is not suspended or debarred or otherwise excluded from participating in the transaction. Condition: As a result of the lack of a suspension and debarment policy, the organization did not document that Sam.gov was checked prior to entering into a contract with a vendor. Questioned costs: None. Context: Five (5) of five (5) vendors selected for testing did not have evidence prior to contracting of a check for suspension and debarment. However, subsequent review showed evidence the vendors were not suspended and debarred. Cause: Employee turnover. Effect: Possible noncompliance with 2 CFR section 200.320(c)(1) - (3). Repeat finding: No. Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. The organization can keep screenshots that Sam.gov was checked or a PDF print out of the web page which includes the date verified. Views of responsible officials: There is no disagreement with the audit finding.
Suspension and Debarment Recommendation: The auditor recommends the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. The organization can keep screenshots that Sam.gov was checked or a PDF print out of the web page which includes the date verified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Consulting with TACHC to develop policies to be approved by the organization’s Board of Directors and implement procedures to properly complete vendor’s sam.gov verification. Name(s) of the contact person(s) responsible for corrective action: David Rodrigues. Planned completion date for corrective action plan: December 2025.
The Organization could not provide documentation to support the amounts tested as key line items within the UDS report. Questioned costs: None. Context: Documentation was not available to support the amounts reported in the UDS report for seven (7) of seven (7) key line items tested. Cause: Employee turnover. Effect: Potential to report inaccurate amounts in the UDS report. Repeat finding: No. Recommendation: We recommend the Organization maintain documentation produced during UDS preparation. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Cluster Assistance Listing Number: 93.224/93.527 Federal Award Identification Number: H80CS12856 Award Periods: March 1, 2023 – February 29, 2024 Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria: Recipients of grants from the Bureau of Primary Health Care Health Center Program are required to submit the Uniform Data System (UDS) report on an annual basis. The UDS report contains various information which has been identified as key line items within the compliance supplement for the health center program cluster. Condition: The Organization could not provide documentation to support the amounts tested as key line items within the UDS report. Questioned costs: None. Context: Documentation was not available to support the amounts reported in the UDS report for seven (7) of seven (7) key line items tested. Cause: Employee turnover. Effect: Potential to report inaccurate amounts in the UDS report. Repeat finding: No. Recommendation: We recommend the Organization maintain documentation produced during UDS preparation. Views of responsible officials: There is no disagreement with the audit finding.
Reporting Recommendation: The auditor recommends the Organization maintain documentation produced during UDS preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Streamlined processes and succession plan to ensure all relevant information for UDS is maintained accurately and accessible for future audits and financial reporting Name(s) of the contact person(s) responsible for corrective action: David Rodrigues. Planned completion date for corrective action plan: December 2025.
FAC accepted this audit on September 7, 2023 — management decision was due March 7, 2024.
FAC accepted this audit on December 11, 2022 — management decision was due June 11, 2023.
A material federal award was omitted from the schedule provided to the auditors as well as a material federal award had an incorrect Assistance Listing Number Identified. Criteria or specific requirement: 2 CFR section 200.510(b). Cause: Expenditures of federal awards reported on the schedule as compared to federal funding reflected in the financial statements and accounting records were not in agreement. Effect: Incomplete identification of a program with approximately $450,000 in expenditures subject to consideration as a major program and incorrect identification of a program with approximately $725,000 in expenditures as a major program. Recommendation: CLA recommends Mt Enterprise Community Health Clinic confirm the origination of funding and reporting requirements for all funding received with the grantor or funding agency. Views of responsible officials: Mt Enterprise Community Health Clinic has complied with all the requirements of the Provider Relief Fund program and unintentionally failed to identify the program as subject to the single audit and include the expenditure on the schedule of expenditures of federal awards. In addition, Mt Enterprise Community Health Clinic incorrectly identified the Assistance Listing Number associated with American Rescue Plan funds received, as there were multiple grants of American Rescue Plan funds received.
Show full finding ▾Hide full finding ▴2021-001 SEFA Preparation. Type of Finding: Material Weakness in Internal Control over Financial Reporting. Condition: A material federal award was omitted from the schedule provided to the auditors as well as a material federal award had an incorrect Assistance Listing Number Identified. Criteria or specific requirement: 2 CFR section 200.510(b). Cause: Expenditures of federal awards reported on the schedule as compared to federal funding reflected in the financial statements and accounting records were not in agreement. Effect: Incomplete identification of a program with approximately $450,000 in expenditures subject to consideration as a major program and incorrect identification of a program with approximately $725,000 in expenditures as a major program. Recommendation: CLA recommends Mt Enterprise Community Health Clinic confirm the origination of funding and reporting requirements for all funding received with the grantor or funding agency. Views of responsible officials: Mt Enterprise Community Health Clinic has complied with all the requirements of the Provider Relief Fund program and unintentionally failed to identify the program as subject to the single audit and include the expenditure on the schedule of expenditures of federal awards. In addition, Mt Enterprise Community Health Clinic incorrectly identified the Assistance Listing Number associated with American Rescue Plan funds received, as there were multiple grants of American Rescue Plan funds received.
2021-001 Corrective Action Plan Mt Enterprise Community Health Clinic unintentionally failed to identify the program as subject to the single audit and include the expenditure on the schedule of expenditures of federal awards. In addition, Mt Enterprise Community Health Clinic incorrectly identified the Assistance Listing Number associated with the American Rescue Plan funds received, as there were multiple grants of American Rescue Plan funds received. To prevent future occurrences of this error, a grant tracking sheet will be maintained that contains all pertinent numbers including the AL number. The grant tracking sheet will be used to complete the Schedule of Expenditures of Federal Awards to ensure that all federal grants are accounted for and that the schedule is complete. The grant tracking spreadsheet will be reconciled to the G/L and Schedule of Expenditures of Federal Awards and will be reviewed by the CFO to make sure that it is compliant.
Mt Enterprise Community Health Clinic is required to prepare and submit period 1 provider relief fund reporting using accurate financial information ain a manner that is compliant with the guidelines set forth by HHS. A portion of the financial information included in the report calculations was not in compliance with the reporting guidelines. Questioned costs: None. Context: The Organization selected for reporting period 1 Option 2, a comparison of actual to budgeted results by quarter. Option 2 required for the time period, quarter 1 of calendar year 2020 through quarter 2 of calendar year 2021 the use of budgeted results from a budget approved prior to March 27, 2020. Quarter 1 and quarter 2 of calendar year 2021 were not from a budget approved prior to March 27, 2020. Cause: The Organization do not have an approved budget prior to March 27, 2020 for quarter 1 2021 or quarter 2 2021 budgeted revenue included in the provider relief fund reporting. Effect: The use of calendar quarter budgets that were not approved prior to March 27, 2020, resulted in a calculation of lost revenue available for a future time period that is not in compliance with the program. Repeat finding: No. Recommendation: Management should implement procedures to ensure the lost revenue is calculated and reported using an option that is appropriate for any future periods and revise the lost revenue amounts on any subsequent filings, if applicable. Views of responsible officials: The Organization understands the context and effect of the audit finding. However, the first quarter of calendar year 2020 was from an approved budget and resulted in a lost revenue calculation that more than covered the organization's award. We believe we are compliant and would have been better suited selecting option 3. There were no financial statement of federal award program audit findings in the prior year.
Show full finding ▾Hide full finding ▴2021-002 Provider Relief Funds. Federal agency: U.S. Department of Health and Human Services (HHS). Federal program title: Provider Relief Fund. AL Number: 93.498. Type of Finding: Significant Deficiency in Internal Control over Compliance. Criteria or specific requirement: Performance and Financial Performance Monitoring 45 CFR ss 75.342. Condition: Mt Enterprise Community Health Clinic is required to prepare and submit period 1 provider relief fund reporting using accurate financial information ain a manner that is compliant with the guidelines set forth by HHS. A portion of the financial information included in the report calculations was not in compliance with the reporting guidelines. Questioned costs: None. Context: The Organization selected for reporting period 1 Option 2, a comparison of actual to budgeted results by quarter. Option 2 required for the time period, quarter 1 of calendar year 2020 through quarter 2 of calendar year 2021 the use of budgeted results from a budget approved prior to March 27, 2020. Quarter 1 and quarter 2 of calendar year 2021 were not from a budget approved prior to March 27, 2020. Cause: The Organization do not have an approved budget prior to March 27, 2020 for quarter 1 2021 or quarter 2 2021 budgeted revenue included in the provider relief fund reporting. Effect: The use of calendar quarter budgets that were not approved prior to March 27, 2020, resulted in a calculation of lost revenue available for a future time period that is not in compliance with the program. Repeat finding: No. Recommendation: Management should implement procedures to ensure the lost revenue is calculated and reported using an option that is appropriate for any future periods and revise the lost revenue amounts on any subsequent filings, if applicable. Views of responsible officials: The Organization understands the context and effect of the audit finding. However, the first quarter of calendar year 2020 was from an approved budget and resulted in a lost revenue calculation that more than covered the organization's award. We believe we are compliant and would have been better suited selecting option 3. There were no financial statement of federal award program audit findings in the prior year.
2021-002 Corrective Action Plan Mt Enterprise Community Health was inundated with HRSA reporting due to the multiple funding we received in response to the Covid-19 Pandemic. In an effort to help health centers deal expeditiously with the Covid crisis some of the funding was given in advance with reporting requirements to follow. The rush to get funding out to address the Covid-19 pandemic crisis resulted in reporting requirements that were developed and implemented very quickly and the reporting requirements were confusing to many health centers. The Provider Relief Funding was one of the instances in which funding was given in advance with reporting requirements to follow. As a result of the confusion surrounding these last-minute reporting requirements, we believe that the former CFO inadvertently selected the wrong reporting option. Should the opportunity to amend the PRF Report occur, we will make the appropriate amendment to the PRF report with a reconciliation and narrative that will support the earning of the PRF funding. To prevent future occurrences of where the incorrect option is selected on a federal provider relief report grant report instructions should be carefully reviewed and a worksheet will be prepared. The worksheet will clearly show lost revenue by comparative quarters and establish clear documentation to strongly support the amounts on the PRF report and concisely show how the amounts on the PRF report were derived. The CFO will oversee this process.
FAC accepted this audit on January 5, 2022 — management decision was due July 5, 2022.
FAC accepted this audit on November 1, 2020 — management decision was due May 1, 2021.
FAC accepted this audit on August 8, 2019 — management decision was due February 8, 2020.
FAC accepted this audit on September 27, 2018 — management decision was due March 27, 2019.
GSA_MIGRATION
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2016-001
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2016-002
FAC accepted this audit on September 28, 2017 — management decision was due March 28, 2018.
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