EIN: 463984362
UEI: Y3DJYKS5KDF5
Data as of August 19, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 9, 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 June 9, 2026, which was (72 days ago).
What is a management decision? →Finding: 2025-001 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing the following errors were noted: • 3 patients were given discounts when applications were incomplete or expired • 1 patient who qualified for discounts was given an incorrect discount • 4 patients with incomes greater than 200% poverty were given discounts • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 9 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2026
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.
2024-002
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 2, 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 June 2, 2025, which was (444 days ago).
What is a management decision? →Finding: 2024-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing the following errors were noted: • 9 patients were given discounts when applications were incomplete or expired • 3 patients who qualified for discounts were given an incorrect discount • 1 patient with income greater than 200% poverty was given a discount • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 14 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
In Finding 2024-002, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2024. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2024-002, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
2023-002
Finding: 2024-003 Cash Management – Federal Grants Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. 93.224 and 93.527 Criteria: Cash Management, 45 CFR 75.305 Condition: During the year, the Organization made three draws of federal funds that were not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes. Cause: The Organization made draws of federal grant funds in advance of making the qualifying expenditures. Effect: Although expenditures were made prior to June 30, 2024, the Organization did not minimize the time elapsing between transfer of funds from the United States Treasury and the disbursement for expenditures. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur. Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
In Finding 2024-003, a condition was noted in which the Organization made three draws of federal funds that were not disbursed in a timely manner for program expenditures. The Organization understands the requirements to disburse federal funds in a timely manner. In response to Finding 2024-003, procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 11, 2023. 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 June 11, 2024, which was (800 days ago).
What is a management decision? →Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
for certain patients with visits to the Organization during the year ended June 30, 2023. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2023-002, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale.
2022-001
Finding: 2023-003 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 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 debarment searches were obtained as required. Effect: 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: Yes 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 employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
In Finding 2023-003, a condition was noted in which 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. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2023-003, procedures will be implemented to ensure debarment searches are completed and properly documented.
2022-002
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 12, 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 June 12, 2023, which was (1165 days ago).
What is a management decision? →Finding: 2022-001 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient?s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts for 8 patients out of a sample of 30 patients during the year ended June 30, 2022. Cause: There were deficiencies in internal controls to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization?s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported Context/Sampling: For 8 of 30 patients selected for testing, the account had an incorrect discount applied. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the electronic health record software be updated to correctly apply sliding fee discounts as intended based on the federal poverty guidelines. It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2023
In Finding 2022-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2022. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2022-001, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale.
2021-003
Finding: 2022-002 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 verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In addition, the Organization did not properly document that certain vendors were not excluded from participating in federal programs. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained or documented as required. Effect: The Organization either did not verify or did not document that certain employees and 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: Yes 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. While the Organization did perform debarment searches on vendors during the year, documentation of the searches was not available. Management will ensure that records are retained to support these searches and will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO
In Finding 2022-002, a condition was noted in which 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. In addition, the Organization did not properly document that certain vendors were not excluded from participating in federal programs. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2022-002, procedures will be implemented to ensure debarment searches are completed and properly documented.
2021-005
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 22, 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 June 22, 2022, which was (1520 days ago).
What is a management decision? →Finding: 2021-003 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient?s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts for 2 patients out of a sample of 20 patients for the year ended June 30, 2021. Cause: There were deficiencies in internal controls to ensure that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization?s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported Context/Sampling: For 2 of 20 patients selected for testing, the account had an incorrect discount applied. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that proper training be given to employees and that the sliding fee discounts be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: March 31, 2022
In Finding 2021-003, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2021. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2021-003, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale.
Finding: 2021-004 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, 2020, contained incorrect data for patient revenue. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges and adjustments were understated by approximately $5,480,000 and $817,000, respectively. 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: Shantelle Simpson, CEO Anticipated Date of Completion: March 31, 2022
In Finding 2021-004, 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. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2021-004, 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.
Finding: 2021-005 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 verify that vendors and certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In addition, the Organization did not obtain bids or quotes for certain purchases in accordance with established policies. Cause: The Organization did not have proper procedures in place to ensure debarment searches and bids or quotes were obtained as required. Effect: The Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In addition, the Organization did not obtain bids or quotes for certain purchases in accordance with established policies. 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 as required. Views of Responsible Officials: Management concurs. The Organization will establish procedures to ensure that debarment searches are completed to verify that all vendors subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. The Organization will also establish procedures to ensure that bids or quotes are obtained in accordance with the Organization?s procurement policy. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: March 31, 2022
In Finding 2021-005, a condition was noted in which the Organization did not ensure that vendors and certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In addition, it was noted that the Organization did not obtain bids or quotes for certain purchases in accordance with established policies. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2021-005, procedures will be implemented to ensure debarment searches are completed to verify that all vendors and 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. Procedures will also be implemented to ensure that the Organization obtains bids or quotes for certain purchases in accordance with its established policies.
Finding: 2021-006 Reporting Federal Programs: Department of Health and Human Services Provider Relief Fund CFDA 93.498 Criteria: Uniform Guidance, Special Reporting Condition: The Provider Relief Fund report submitted to the U.S. Department of Health and Human Services (DHHS) contained incorrect data for loss of revenue. The comparison of revenue from 2019, 2020, and 2021 was reported incorrectly. The revenue was reported as a loss of $2.8 million, but the actual revenue was a gain of approximately $6.2 million. Cause: The above exception resulted from errors in preparing the Provider Relief Fund special reporting. Effect: The DHHS reviews the Provider Relief Fund data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Questioned Costs: None reported. The Organization had qualifying healthcare related expenses that were not reimbursed by another source that substantiated the use of the Provider Relief Funds. However, the Organization incorrectly reported the use of the funds as being applied to patient care lost revenues rather than being used to reimburse the Organization for qualifying healthcare related expenses attributable to coronavirus. 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 revenue sources are reported and reconciled to the Provider Relief Fund report. The DHHS should be informed of the error and the Provider Relief Fund special report should be revised and resubmitted. Views of Responsible Officials: Management concurs. Efforts will be made to ensure that the patient revenue from all sources are reconciled to the actual revenue and reported correctly on the Provider Relief Fund special report. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: March 31, 2022
In Finding 2021-006, a condition was noted in which the Provider Relief Fund report submitted to the U.S. Department of Health and Human Services (DHHS) contained incorrect data for loss of revenue. The comparison of revenue from 2019, 2020, and 2021 was reported incorrectly. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2021-006, efforts will be made to ensure that the patient revenue from all sources are reconciled to the actual revenue and reported correctly on the Provider Relief Fund report.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 29, 2020. 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 June 29, 2021, which was (1878 days ago).
What is a management decision? →Finding: 2020-001 Cash Management Federal Programs: Department of Health and Human Services Health Center Cluster, CFDA 93.224 Grant No. H8DCS 36495 Criteria: Cash Management, 45 CFR 75.305 Condition: During the year the Organization drew $46,680 of federal funds that were not disbursed for program expenses. The Organization also continued to maintain advanced funds of $210,683 from the prior year grant. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization. Context: One grant draw made by the Organization during the fiscal year was determined to be an advanced draw. Cause: The Organization did not identify qualifying expenditures prior to drawing down grant funds. Effect: Grant funds were drawn in advance of qualifying expenditures resulting in unearned federal grant funds. Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur. Auditee?s Response and Corrective Action Plan: Finance staff understands the requirements to draw funds for qualifying expenditures only. Procedures will be established to ensure that draws are not made in excess of the allowable expenditure of the Organization. The $46,680 advanced federal funds were used to reduce the current year federal draws. Contact Person: Reuben Pettiford, CEO Anticipated Date of Completion: January 31, 2021 Questioned Costs: Cash Management CFDA 93.224 $ 46,680 Total Questioned Cost $ 46,680
Corrective Action Plan In Finding 2020-001, a condition was noted in which the Organization failed to comply with grant guidelines regarding grant draws. One federal grant draw made by the Organization during the fiscal year were determined to be an advanced draw. Efforts should be made to ensure advance draws of federal funds do not occur. Management recognizes the importance of complying with grant guidelines regarding federal grant draws. In response to Finding 2020-001, policies and procedures will be established to ensure that draws are not made in excess of the allowable expenditure of the Organization. The $46,680 advanced federal funds were used to reduce the current year federal draws. Reuben Pettiford Chief Executive Officer
2019-002
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on January 19, 2020. 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 July 19, 2020, which was (2223 days ago).
What is a management decision? →Finding: 2019-001 Monthly time/activity reports not maintained for employees Federal Programs: Department of Health and Human Services Health Center Cluster, CFDA 93.224 & 93.527 Grant No. H80CS28348 Criteria: Cost principles, 2 CFR 200.412 Condition: Time/activity reports (time sheets) are not maintained for salaried employees and several employees? wages were allocated to federal grant expenses without regard to reasonable allocations of nonfederal activities. Context: Federal documentation guidelines permit the grantee to document employee time and effort using either physical or electronic records, such as recording information in online timekeeping systems and electronic spreadsheet systems. Regardless if the medium used, the documentation must identify the activities of the employee worked on (such as federal or state programs) and the amount of time the employee worked on each activity. A review of payroll disbursements revealed that monthly time and effort certifications for salaried employees were not maintained, and several employees? wages were allocated to federal grant expenses without regard to reasonable allocations of nonfederal activities. Cause: The Organization?s policy does not require salaried employees to certify time and efforts on a no less than monthly basis or employees? wages are not allocated to federal grant expenses with regard to reasonable allocations of nonfederal activities. Effect: Failure to comply with federal requirements regarding personnel cost and time and effort, as well as allocation of employee wages to federal grant expenses with regarding to reasonable allocation of non-federal activities could result in a reduction of grant funds. Recommendation: Procedures should be established to maintain time and effort certifications by all salaried employees and wages should be allocated to federal grant expenses utilizing reasonable allocations of nonfederal activities. It is recommended time and effort certifications be prepared on a bi-weekly basis to coincide with the payroll cycle. These certifications should document the hours paid for these employees. Auditee?s Response and Corrective Action Plan: Procedures will be established to ensure that employees certify time and effort on a bi-weekly basis and wages be allocated to federal grant expenses regarding reasonable allocations of nonfederal activities. Contact Person: Reuben Pettiford, CEO Anticipated Date of Completion: December 31, 2019 Questioned Costs: None
Corrective Action Plan In Finding 2019-001, a condition was noted that time/activity reports (time sheets) are not maintained for salaried employees and several employees? wages were allocated to federal grant expenses without regard to reasonable allocations of nonfederal activities. Failure to comply with federal requirements regarding personnel cost and time and effort, as well as allocation of employee wages to federal grant expenses based on a reasonable allocation of non-federal activities could result in a reduction of grant funds. Management recognizes the importance of complying with grant guidelines regarding time and activity reports. In response to Finding 2019-001, policies and procedures will be established to ensure that employees certify time and effort on a bi-weekly basis and wages will be allocated to federal grant expenses regarding reasonable allocations of nonfederal activities. Policies will be updated, and the new procedures put in place by December 31, 2019.
2018-004
Finding: 2019-002 Cash Management Federal Programs: Department of Health and Human Services Health Center Cluster, CFDA 93.224 & 93.527 Grant No. H80CS28348 Criteria: Cash Management, 45 CFR 75.305 Condition: During the year the Organization drew federal funds that were not disbursed for program expenses. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization. Context: Two of the four cash draws made by the Organization during the fiscal year were determined to be advanced draws. Cause: The Organization did not identify qualifying expenditures prior to drawing down two of their four grant draws. Effect: Grant funds were drawn in advance of qualifying expenditures. The final two draws included supplementary funds that were not earned as of the end of the grant period and are reflected as deferred grant revenue. Portions of these funds were eligible for carry forward based on the grant terms. Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur. Auditee?s Response and Corrective Action Plan: Finance staff understands the requirements to draw funds for qualifying expenditures only. Procedures will be established to ensure that draws are not made in excess of the allowable expenditure of the Organization. Contact Person: Reuben Pettiford, CEO Anticipated Date of Completion: December 31, 2019 Questioned Costs: Cash Management CFDA 93.224 $ 109,610 CFDA 93.527 101,073 Total Questioned Cost $ 210,683
In Finding 2019-002, a condition was noted in which the Organization failed to comply with grant guidelines regarding grant draws. Two of the four federal grant draws made by the Organization during the fiscal year were determined to be advanced draws. Efforts should be made to ensure advance draws of federal funds do not occur. Management recognizes the importance of complying with grant guidelines regarding federal grant draws. In response to Finding 2019-002, policies and procedures will be established to ensure that draws are not made in excess of the allowable expenditure of the Organization. Policies will be updated, and the new procedures put in place by December 31, 2019.
Finding: 2019-003 Procurement-Suspension and Debarment Federal Programs: Department of Health and Human Services Health Center Cluster, CFDA 93.224 & 93.527 Grant No. H80CS28348 Criteria: Uniform Guidance, Compliance Supplement, Executive Order 12549 Condition: Procedures have not been established to ensure that the Organization does not purchase contractual services expected to equal or exceed $25,000 from parties listed on the government-wide System for Award Management (SAM) in accordance with the OMB guidelines. The SAM contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority. Context: The review of Organizational policies and interviews with various personnel disclosed the deficiency noted above. Cause: Failure to establish a policy that requires management to confirm that contractual services expected to equal or exceed $25,000 are not purchased from parties debarred, suspended, or otherwise excluded from participating in federal funds. Effect: Failure to comply with this federal requirement could result in the Organization becoming ineligible to receive federal funds. Recommendation: Procedures should be established to ensure that purchases of contractual services equal to or exceeding $25,000 will not include ineligible parties as listed on the SAM. Auditee?s Response and Corrective Action Plan: Procedures will be established to ensure that contract services expected to equal or exceed $25,000 will be parties that are not disqualified by the government-wide System for Award Management (SAM) in accordance with the OMB guidelines. Contact Person: Reuben Pettiford, CEO Anticipated Date of Completion: December 31, 2019 Questioned Costs: None
In Finding 2019-003, a condition was noted in which the Organization failed to establish procedures to ensure that the Organization does not purchase contractual services expected to equal or exceed $25,000 from parties listed on the government-wide System for Award Management (SAM) in accordance with the OMB guidelines. The SAM contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority. Management recognizes the importance of complying with SAM guidelines. In response to Finding 2019-003, procedures will be established to ensure that contract services expected to equal or exceed $25,000 will be parties that are not disqualified by the government-wide System for Award Management (SAM) in accordance with the OMB guidelines. Policies will be updated, and the new procedures put in place by December 31, 2019.
Finding: 2019-004 - Board Member Compliance Federal Programs: Department of Health and Human Services Health Center Cluster, CFDA 93.224 & 93.527 Grant No. H80CS28348 Criteria: BPHC Policy Information Notice 98-23 Condition: A majority of the board members or their immediate family are not users of the Organization. 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 health center?s strategic direction and policy. Context: During the audit period only five of the eleven board members ?utilized the health center as their principal source of primary health care? documented by the Organization?s medical records. 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 Organization. Effect: This non-compliance with federal grant requirements could result in a reduction of grant funds or additional grant restrictions. Recommendation: It is recommended that procedures be established to ensure that more than fifty percent of board members are active users of the Organization. Auditee?s Response and Corrective Action Plan: Management concurs with the audit finding. As of July 2019, more than fifty percent of the board members are users of the Organization. Contact Person: Reuben Pettiford, CEO Anticipated Date of Completion: December 31, 2019 Questioned Costs: None
In Finding 2019-004, a condition was noted in which A majority of the board members or their immediate family are not users of the Organization. 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 health center?s strategic direction and policy. Management recognizes the importance of complying with board member compliance guidelines. In response to Finding 2019-004, as of July 2019 more than fifty percent of the board members are users of the Organization.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 3, 2019. 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 3, 2019, which was (2543 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
2017-003
GSA_MIGRATION
GSA_MIGRATION
2017-010
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 29, 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 September 29, 2018, which was (2882 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
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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