EIN: 520902461
UEI: SPWLNNXZNZE9
Data as of August 26, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 26, 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 November 26, 2026 (91 days from today).
What is a management decision? →Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E Condition – A sample of 80 expenditures were selected from ALN No. 93.788, which included the following populations: • Payroll expenditures - a total of 487 total items totaling $1,589,426. • Direct expenditures – a total of 284 total items totaling $310,843 The samples were not, and are not intended to be, statistically valid. Of the expenditures tested the following items were determined to lack appropriate supporting documentation to support being charged to the grant program: • Payroll expenditures - 40 items totaling $10,310 • Direct expenditures – 38 items totaling $872 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. Questioned costs – $8,561. These questioned costs were determined by an allocation charged to both direct expenditures and payroll expenses greater than actual time consistent with usage related to the grant. Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs. Identification as a repeat finding, if applicable – Repeat finding (see 2024-002 and 2023-003). Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E Condition – A sample of 80 expenditures were selected from ALN No. 93.788, which included the following populations: • Payroll expenditures - a total of 487 total items totaling $1,589,426. • Direct expenditures – a total of 284 total items totaling $310,843 The samples were not, and are not intended to be, statistically valid. Of the expenditures tested the following items were determined to lack appropriate supporting documentation to support being charged to the grant program: • Payroll expenditures - 40 items totaling $10,310 • Direct expenditures – 38 items totaling $872 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. Questioned costs – $8,561. These questioned costs were determined by an allocation charged to both direct expenditures and payroll expenses greater than actual time consistent with usage related to the grant. Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs. Identification as a repeat finding, if applicable – Repeat finding (see 2024-002 and 2023-003). Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis.
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the continued deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditures charged to grant programs and reaffirms its commitment to achieving full compliance. To address this repeat finding, Tuerk House has implemented or is continuing to implement the following corrective actions: • Implemented a formal time and effort certification process requiring employees to certify actual time worked on federal grant activities on a regular basis, rather than relying on budgeted allocations. • Developed a standardized cost allocation methodology that aligns with actual grant activity and is supported by verifiable documentation. • Required that all expenditures charged to federal awards be supported by complete and accurate source documentation, including vendor invoices, timesheets, and approvals. • Established a document retention policy consistent with 2 CFR § 200.334 to ensure all supporting records are retained for the required period and readily accessible for audit or review. Training sessions for program and finance staff have been conducted, and ongoing training will continue to ensure consistent understanding and application of these updated policies and procedures. Organization Contact Person Responsible for Corrective Action – Kisun Peters, Director of Finance Anticipated Completion Date – June 30, 2026
2024-002, 2023-003
Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 2 procurements were selected from a population of 5 totaling $209,643. For suspension and debarment testing, a sample of 1 was selected from a population of 4 totaling $192,737. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance report. • Procurement: 2 item totaling $115,229 • Suspension and debarment: 1 item totaling $80,974 Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Repeat finding (see 2024-003 and 2023-004) Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 2 procurements were selected from a population of 5 totaling $209,643. For suspension and debarment testing, a sample of 1 was selected from a population of 4 totaling $192,737. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance report. • Procurement: 2 item totaling $115,229 • Suspension and debarment: 1 item totaling $80,974 Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Repeat finding (see 2024-003 and 2023-004) Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
Tuerk House, Inc. acknowledges the finding related to procurement and suspension and debarment requirements and recognizes the continued need for strengthened internal controls to ensure full compliance with Uniform Guidance and the Organization’s procurement policies. To address this repeat finding, Tuerk House has implemented or is continuing to implement the following corrective actions: • Updated the procurement policy to explicitly include steps for verifying all vendors against the federal government’s System for Award Management (SAM) exclusion list prior to engaging in any procurement activity funded by federal awards. • Implemented a procurement checklist and documentation protocol to ensure proper procedures are followed for purchases exceeding $10,000, including competitive bidding, price or rate quotations, and appropriate vendor selection justification. • Conducted mandatory training for finance and program staff on updated procurement procedures, including documentation and vendor vetting protocols, with ongoing training to reinforce compliance. • Established a centralized record-keeping system to retain documentation related to procurement, vendor selection, and debarment checks in accordance with 2 CFR Part 200 and 2 CFR § 180. The Organization remains committed to full compliance and will continue to ensure that all future procurements charged to federal awards meet the applicable requirements. Organization Contact Person Responsible for Corrective Action – Kisun Peters, Director of Finance Anticipated Completion Date – June 30, 2026
2024-003, 2023-004
FAC accepted this audit on July 8, 2025 — management decision was due January 8, 2026.
Block Grants for Prevention and Treatment of Substance Abuse ALN No. 93.959 U.S. Department of Health and Human Services Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E, and Period of Performance – 2 CFR sections 200.308, 200.309, and 200.403(h) Condition – A sample of 80 expenditures were selected from each of the following populations: • ALN No. 93.959 – 1,152 items totaling $1,077,416 • ALN No. 93.788 – 1,222 items totaling $2,537,080 The samples were not, and are not intended to be, statistically valid. Of the 80 expenditures tested from each grant program, the following were determined to lack appropriate supporting documentation to support being charged to grant program: • ALN No. 93.959 - 41 items totaling $25,810, including projected errors over the total population totaling $191,145 • ALN No. 93.788 - 10 items totaling $72,347, including projected errors over the total population totaling $207,012 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting and lacked evidence of supporting invoices. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. In addition, the Organization charged expenditures to the grant programs without evidence of supporting invoices. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. In addition, costs charged to the grant could not be supported by actual invoices. Questioned costs – • ALN No. 93.959 - $25,810 • ALN No. 93.788 - $72,347 Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs and did not maintain proper supporting invoices. Identification as a repeat finding, if applicable – Repeat finding (see 2023-003) Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis. In addition, management should implement a document retention policy consistent with 2 CFR 200.334.
Show full finding ▾Hide full finding ▴Block Grants for Prevention and Treatment of Substance Abuse ALN No. 93.959 U.S. Department of Health and Human Services Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E, and Period of Performance – 2 CFR sections 200.308, 200.309, and 200.403(h) Condition – A sample of 80 expenditures were selected from each of the following populations: • ALN No. 93.959 – 1,152 items totaling $1,077,416 • ALN No. 93.788 – 1,222 items totaling $2,537,080 The samples were not, and are not intended to be, statistically valid. Of the 80 expenditures tested from each grant program, the following were determined to lack appropriate supporting documentation to support being charged to grant program: • ALN No. 93.959 - 41 items totaling $25,810, including projected errors over the total population totaling $191,145 • ALN No. 93.788 - 10 items totaling $72,347, including projected errors over the total population totaling $207,012 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting and lacked evidence of supporting invoices. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. In addition, the Organization charged expenditures to the grant programs without evidence of supporting invoices. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. In addition, costs charged to the grant could not be supported by actual invoices. Questioned costs – • ALN No. 93.959 - $25,810 • ALN No. 93.788 - $72,347 Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs and did not maintain proper supporting invoices. Identification as a repeat finding, if applicable – Repeat finding (see 2023-003) Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis. In addition, management should implement a document retention policy consistent with 2 CFR 200.334.
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditures charged to grant programs. To address this finding, Tuerk House is taking the following corrective actions: ·Implementing a formal time and effort certification process that requires employees to certify actual time worked on federal grant activities on a regular basis, rather than relying on budgeted allocations. ·Developing a standardized cost allocation methodology that aligns with actual grant activity and is supported by verifiable documentation. ·Requiring that all expenditures charged to federal awards be supported by complete and accurate source documentation, including vendor invoices, timesheets, and approvals. ·Establishing a document retention policy consistent with 2 CFR § 200.334 to ensure all supporting records are retained for the required period and readily accessible for audit or review. Training sessions for program and finance staff will be conducted to ensure consistent understanding and application of these updated policies and procedures. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
2023-003, 2022-003
Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 1 procurement was selected from a population of 5 totaling $487,910. For suspension and department testing, a sample of 1 was selected from a population of 3 totaling $464,333. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance requirement: • Procurement: 1 item totaling $59,791, including projected errors over the total population totaling $487,910 • Suspension and debarment: 1 item totaling $59,791, including projected errors over the total population totaling $464,333 Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Repeat finding (see 2022-004 and 2023-004) Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 1 procurement was selected from a population of 5 totaling $487,910. For suspension and department testing, a sample of 1 was selected from a population of 3 totaling $464,333. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance requirement: • Procurement: 1 item totaling $59,791, including projected errors over the total population totaling $487,910 • Suspension and debarment: 1 item totaling $59,791, including projected errors over the total population totaling $464,333 Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Repeat finding (see 2022-004 and 2023-004) Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
Tuerk House, Inc. acknowledges the finding related to procurement and suspension and debarment requirements and recognizes the need for strengthened internal controls to ensure continued compliance with Uniform Guidance and the Organization's procurement policies. To address this repeat finding, Tuerk House is taking the following corrective actions: ·Updating the procurement policy to explicitly include steps for verifying all vendors against the federal government's System for Award Management (SAM) exclusion list prior to engaging in any procurement activity funded by federal awards. ·Implementing a procurement checklist and documentation protocol to ensure proper procedures are followed for purchases exceeding $10,000, including competitive bidding, price or rate quotations, and appropriate justification for vendor selection. ·Conducting mandatory training for finance and program staff on updated procurement procedures, including documentation and vendor vetting protocols. ·Establishing a centralized record-keeping system to retain documentation related to procurement, vendor selection, and debarment checks in accordance with 2 CFR Part 200 and 2 CFR 180. The Organization is committed to full compliance and will ensure that all future procurements charged to federal awards meet the applicable requirements. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
2023-004, 2022-004
Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization’s annual expenditure reporting did not agree to the underlying grant expenditure support. In addition, the Organization did not properly report certain information in its quarterly programmatic reports. Cause – The Organization did not have necessary internal controls to properly identify and report eligible grant expenditures. In addition, the Organization did not have controls in place to support amounts reported in quarterly programmatic reporting requirements. Effect or potential effect– The Organization incorrectly reported grant expenditures and programmatic statistics, such as total unique patients. Questioned Costs – None Context – A sample of one financial report was tested out of the total population of 2 financial reports. In addition, a sample of one special report was tested out of the total population of 4 special reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the financial and special reports were not accurately reported. Identification as a repeat finding, if applicable – Repeat finding (see 2022-005 and 2023-005) Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization’s annual expenditure reporting did not agree to the underlying grant expenditure support. In addition, the Organization did not properly report certain information in its quarterly programmatic reports. Cause – The Organization did not have necessary internal controls to properly identify and report eligible grant expenditures. In addition, the Organization did not have controls in place to support amounts reported in quarterly programmatic reporting requirements. Effect or potential effect– The Organization incorrectly reported grant expenditures and programmatic statistics, such as total unique patients. Questioned Costs – None Context – A sample of one financial report was tested out of the total population of 2 financial reports. In addition, a sample of one special report was tested out of the total population of 4 special reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the financial and special reports were not accurately reported. Identification as a repeat finding, if applicable – Repeat finding (see 2022-005 and 2023-005) Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report.
Tuerk House, Inc. acknowledges the finding related to the accuracy of financial and programmatic reporting. We recognize the critical importance of maintaining accurate and supportable reporting for federal awards, particularly in light of this being a repeat finding. In response, Tuerk House has initiated corrective actions to improve internal controls over financial and programmatic reporting. These actions include: ·Establishing a standardized reconciliation process to ensure that all amounts reported in financial reports are tied directly to supporting documentation from the general ledger and other internal financial systems. ·Implementing a dual-review protocol requiring reports to be reviewed and approved by both finance and program staff before submission to funding agencies. · Providing targeted training to relevant personnel on grant reporting requirements, with an emphasis on reporting accuracy, documentation standards, and deadlines. ·Coordinating regular meetings between finance and program departments to align data and ensure consistency between financial and programmatic reporting (e.g., patient counts, service metrics, etc.). ·Developing a reporting calendar to track all reporting requirements and facilitate timely and accurate submissions. We are committed to ensuring accurate and compliant reporting going forward and will monitor implementation closely to prevent recurrence. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
2023-005, 2022-005
FAC accepted this audit on July 8, 2025 — management decision was due January 8, 2026.
Block Grants for Prevention and Treatment of Substance Abuse ALN No. 93.959 U.S. Department of Health and Human Services Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E, and Period of Performance – 2 CFR sections 200.308, 200.309, and 200.403(h) Condition – A sample of 80 expenditures were selected from each of the following populations: • ALN No. 93.959 – 1,631 items totaling $1,399,666 • ALN No. 93.788 – 1,728 items totaling $2,664,710 The samples were not, and are not intended to be, statistically valid. Of the 80 expenditures tested from each grant program, the following were determined to lack appropriate supporting documentation to support being charged to grant program: • ALN No. 93.959 - 47 items totaling $48,756, including projected errors over the total population totaling $582,093 • ALN No. 93.788 - 7 items totaling $30,061, including projected errors over the total population totaling $138,133 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting and lacked evidence of supporting invoices. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. In addition, the Organization charged expenditures to the grant programs without evidence of supporting invoices. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. In addition, costs charged to the grant could not be supported by actual invoices. Questioned costs – • ALN No. 93.959 - $48,756 • ALN No. 93.788 - $30,061 Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs and did not maintain proper supporting invoices. Identification as a repeat finding, if applicable – Repeat finding (2022-003). Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis. In addition, management should implement a document retention policy consistent with 2 CFR 200.334.
Show full finding ▾Hide full finding ▴Block Grants for Prevention and Treatment of Substance Abuse ALN No. 93.959 U.S. Department of Health and Human Services Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E, and Period of Performance – 2 CFR sections 200.308, 200.309, and 200.403(h) Condition – A sample of 80 expenditures were selected from each of the following populations: • ALN No. 93.959 – 1,631 items totaling $1,399,666 • ALN No. 93.788 – 1,728 items totaling $2,664,710 The samples were not, and are not intended to be, statistically valid. Of the 80 expenditures tested from each grant program, the following were determined to lack appropriate supporting documentation to support being charged to grant program: • ALN No. 93.959 - 47 items totaling $48,756, including projected errors over the total population totaling $582,093 • ALN No. 93.788 - 7 items totaling $30,061, including projected errors over the total population totaling $138,133 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting and lacked evidence of supporting invoices. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. In addition, the Organization charged expenditures to the grant programs without evidence of supporting invoices. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. In addition, costs charged to the grant could not be supported by actual invoices. Questioned costs – • ALN No. 93.959 - $48,756 • ALN No. 93.788 - $30,061 Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs and did not maintain proper supporting invoices. Identification as a repeat finding, if applicable – Repeat finding (2022-003). Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis. In addition, management should implement a document retention policy consistent with 2 CFR 200.334.
The Organization acknowledges this repeat finding and will take steps to address the deficiencies noted. Since the prior year's audit, management will implement updated procedures to strengthen internal controls around documentation of allowable costs charged to federal awards. These measures include the development of a formal time and effort reporting system, which requires all grant-funded employees to submit periodic certifications that reflect actual hours worked and funding source allocation. Supervisors are now required to review and approve these certifications to ensure alignment with actual program activities. Additionally, the Organization will reinforce its invoice documentation and review process. All expenditures charged to the Block Grant and Opioid STR programs must now be supported by detailed invoices and documentation that clearly demonstrate allocability, allowability, and consistency with the approved grant budget and period of performance. These requirements are monitored through monthly reviews by the finance department. The Organization has also adopted a document retention policy aligned with 2 CFR §200.334, and relevant staff have received training on documentation and compliance requirements for federal awards. These corrective actions are being actively monitored by the Director of Finance to ensure full implementation and ongoing compliance. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
2022-003
Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 2 procurements was selected from a population of 7 totaling $368,608. For suspension and department testing, a sample of 1 was selected from a population of 3 totaling $310,009. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance requirement: • Procurement: 2 items totaling $209,209, including projected errors over the total population totaling $368,608 • Suspension and debarment: 1 item totaling $162,900, including projected errors over the total population totaling $310,009 Procurement procedures were not followed for vendors with greater than $10,000 in purchases of goods or services charged to the federal award. In addition, the Organization does not have adequate policies governing suspension and debarment requirements for the purchase of goods or services charged to federal awards. Specifically, the Organization did not verify that vendors were not suspended, debarred, or otherwise excluded. Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Repeat finding (see 2022-004) Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 2 procurements was selected from a population of 7 totaling $368,608. For suspension and department testing, a sample of 1 was selected from a population of 3 totaling $310,009. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance requirement: • Procurement: 2 items totaling $209,209, including projected errors over the total population totaling $368,608 • Suspension and debarment: 1 item totaling $162,900, including projected errors over the total population totaling $310,009 Procurement procedures were not followed for vendors with greater than $10,000 in purchases of goods or services charged to the federal award. In addition, the Organization does not have adequate policies governing suspension and debarment requirements for the purchase of goods or services charged to federal awards. Specifically, the Organization did not verify that vendors were not suspended, debarred, or otherwise excluded. Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Repeat finding (see 2022-004) Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
The Organization acknowledges this repeat finding and is taking action to strengthen internal controls around procurement and suspension and debarment compliance. As part of corrective measures initiated in response to the previous year's audit, the Organization is updating its procurement policy to require formal verification that all vendors receiving more than $10,000 in federal funds are not suspended, debarred, or otherwise excluded from participation in federal programs. This verification is now conducted through the federal SAM.gov database and must be documented prior to contract execution or payment. Additionally, staff involved in procurement have received training on Uniform Guidance requirements, with a particular focus on vendor selection, documentation standards, and the necessity of confirming vendor eligibility for federal awards. A checklist and documentation log have been incorporated into the procurement process to ensure all steps, including debarment checks, are consistently followed and retained in the grant file. The finance and compliance teams will now conduct quarterly internal reviews of all procurements over $10,000 to confirm that proper procedures and documentation are in place. These controls are overseen by the Director of Finance, with escalation protocols in place for any exceptions identified. These procedures are being implemented to ensure full compliance going forward. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
2022-004
Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization’s annual expenditure reporting did not agree to the underlying grant expenditure support. In addition, the Organization did not properly report certain information in its quarterly programmatic reports. Cause – The Organization did not have necessary internal controls to properly identify and report eligible grant expenditures. In addition, the Organization did not have controls in place to support amounts reported in quarterly programmatic reporting requirements. Effect or potential effect– The Organization incorrectly reported grant expenditures and programmatic statistics, such as total unique patients. Questioned Costs – None Context – A sample of one financial report was tested out of the total population of 2 financial reports. In addition, a sample of one special report was tested out of the total population of 4 special reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the financial and special reports were not accurately reported. Identification as a repeat finding, if applicable – Repeat finding (see 2022-005) Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization’s annual expenditure reporting did not agree to the underlying grant expenditure support. In addition, the Organization did not properly report certain information in its quarterly programmatic reports. Cause – The Organization did not have necessary internal controls to properly identify and report eligible grant expenditures. In addition, the Organization did not have controls in place to support amounts reported in quarterly programmatic reporting requirements. Effect or potential effect– The Organization incorrectly reported grant expenditures and programmatic statistics, such as total unique patients. Questioned Costs – None Context – A sample of one financial report was tested out of the total population of 2 financial reports. In addition, a sample of one special report was tested out of the total population of 4 special reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the financial and special reports were not accurately reported. Identification as a repeat finding, if applicable – Repeat finding (see 2022-005) Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report.
The Organization acknowledges this repeat finding and is taking action to improve the accuracy and oversight of financial and programmatic reporting for federally funded programs. In response, internal controls have been strengthened to ensure that all expenditure reports and quarterly programmatic reports are fully supported by underlying documentation from the accounting system and program records. A standardized grant reporting checklist has been developed and is now required to be completed for each submission. This checklist includes steps for reconciling reported expenditures with the general ledger and verifying that all programmatic metrics, such as unduplicated patient counts, are accurate and appropriately sourced. Reports are reviewed and approved by both the management of finance and program departments prior to submission. Quarterly training and periodic reviews have also been instituted for finance and program staff involved in grant reporting to reinforce proper procedures and improve coordination across departments. These corrective actions are intended to ensure accurate, compliant, and timely reporting in alignment with 45 CFR 75.342 and Uniform Guidance requirements. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
2022-005
FAC accepted this audit on July 8, 2025 — management decision was due January 8, 2026.
Block Grants for Prevention and Treatment of Substance Abuse ALN No. 93.959 U.S. Department of Health and Human Services Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E, and Period of Performance – 2 CFR sections 200.308, 200.309, and 200.403(h) Condition – A sample of 80 expenditures were selected from each of the following populations: • ALN No. 93.959 – 1,839 items totaling $1,243,944 • ALN No. 93.788 – 1,502 items totaling $2,285,983 The samples were not, and are not intended to be, statistically valid. Of the 80 expenditures tested from each grant program, the following were determined to lack appropriate supporting documentation to support being charged to grant program: • ALN No. 93.959 - 51 items totaling $26,145, including projected errors over the total population totaling $348,063 • ALN No. 93.788 - 6 items totaling $18,183, including projected errors over the total population totaling $165,074 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting and lacked evidence of supporting invoices. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. In addition, the Organization charged expenditures to the grant programs without evidence of supporting invoices. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. In addition, costs charged to the grant could not be supported by actual invoices. Questioned costs – • ALN No. 93.959 - $26,145 • ALN No. 93.788 - $18,183 Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs and did not maintain proper supporting invoices. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis. In addition, management should implement a document retention policy consistent with 2 CFR 200.334.
Show full finding ▾Hide full finding ▴Block Grants for Prevention and Treatment of Substance Abuse ALN No. 93.959 U.S. Department of Health and Human Services Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed and Unallowed and Cost Principles – 2 CFR Part 200, Subpart E, and Period of Performance – 2 CFR sections 200.308, 200.309, and 200.403(h) Condition – A sample of 80 expenditures were selected from each of the following populations: • ALN No. 93.959 – 1,839 items totaling $1,243,944 • ALN No. 93.788 – 1,502 items totaling $2,285,983 The samples were not, and are not intended to be, statistically valid. Of the 80 expenditures tested from each grant program, the following were determined to lack appropriate supporting documentation to support being charged to grant program: • ALN No. 93.959 - 51 items totaling $26,145, including projected errors over the total population totaling $348,063 • ALN No. 93.788 - 6 items totaling $18,183, including projected errors over the total population totaling $165,074 The Organization did not have adequate supporting documentation demonstrating actual time and effort reporting and lacked evidence of supporting invoices. Cause – The Organization charged budgeted percentages to the grant programs without a system in place to monitor and track that actual time and effort was consistent with budgeted percentages. In addition, the Organization charged expenditures to the grant programs without evidence of supporting invoices. Effect or potential effect – Costs charged to the grant programs could have varied from actual time and effort. In addition, costs charged to the grant could not be supported by actual invoices. Questioned costs – • ALN No. 93.959 - $26,145 • ALN No. 93.788 - $18,183 Context – The Organization did not have a reasonable methodology of allocating costs to these grant programs and did not maintain proper supporting invoices. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – Management should implement policies and procedures that strengthen internal control over compliance in relation to activities allowed and cost principles. The policy and procedure should be designed to ensure that a reasonable allocation methodology is implemented and followed or that time and effort is certified by the employee on a regular basis. In addition, management should implement a document retention policy consistent with 2 CFR 200.334.
The Organization agrees with the finding and acknowledges the need for strengthened internal controls and documentation related to time and effort reporting, as well as the allocation of expenditures to federally funded grant programs. To address the deficiencies noted, the Organization is developing and implementing formal time and effort reporting procedures to ensure that personnel costs charged to federal grants are supported by actual activity records and certified by employees on a regular basis. This will include the adoption of time distribution systems that comply with 2 CFR Part 200 Subpart E and the requirement for supervisory approval of time reports. Additionally, the Organization will revise its expenditure review and approval processes to require that all costs charged to federal programs are supported by appropriate documentation, including vendor invoices and receipts. Staff involved in grant management and accounting will receive training on federal cost principles, documentation requirements, and period of performance compliance. A document retention policy in accordance with 2 CFR 200.334 will also be established to ensure that all supporting documentation is maintained and readily available for audit and program oversight. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 3 procurements was selected from a population of 12 totaling $537,276. For suspension and department testing, a sample of 2 was selected from a population of 7 totaling $469,071. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance requirement: • Procurement: 3 items totaling $216,847, including projected errors over the total population totaling $537,276 • Suspension and debarment: 2 items totaling $157,617, including projected errors over the total population totaling $469,071 Procurement procedures were not followed for vendors with greater than $10,000 in purchases of goods or services charged to the federal award. In addition, the Organization does not have adequate policies governing suspension and debarment requirements for the purchase of goods or services charged to federal awards. Specifically, the Organization did not verify that vendors were not suspended, debarred, or otherwise excluded. Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Not a repeat finding Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement, Suspension and Debarment – 45 CFR 75.329, 2 CFR 180 Condition – For procurement testing, a sample of 3 procurements was selected from a population of 12 totaling $537,276. For suspension and department testing, a sample of 2 was selected from a population of 7 totaling $469,071. The samples were not, and are not intended to be, statistically valid. Of the samples tested, the following were determined to lack appropriate supporting documentation for compliance requirement: • Procurement: 3 items totaling $216,847, including projected errors over the total population totaling $537,276 • Suspension and debarment: 2 items totaling $157,617, including projected errors over the total population totaling $469,071 Procurement procedures were not followed for vendors with greater than $10,000 in purchases of goods or services charged to the federal award. In addition, the Organization does not have adequate policies governing suspension and debarment requirements for the purchase of goods or services charged to federal awards. Specifically, the Organization did not verify that vendors were not suspended, debarred, or otherwise excluded. Cause – The Organization did not comply with their procurement policy. In addition, the Organization does not include a review of the federal suspended and debarment party list as part of the Organization's procurement policy. Effect or potential effect – Procurement methodology was not followed for vendor with expenses of over $10,000. In addition, that did not adhere to the federal government's suspension and debarment compliance requirements. Questioned Costs – None Context – The Organization did not have adequate policies and procedures to ensure procurement, suspension, and debarment requirements were met prior to the purchase of goods or services charged to federal awards. Upon further discussion with Tuerk House, Inc., no procurement, suspension and debarment procedures were performed on any vendors. Identification as a repeat finding – Not a repeat finding Recommendation – We recommend management continue to ensure all personnel understand the procurement policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that vendors, especially those over $10,000, are selected and vetted in accordance with policy and Uniform Guidance. In addition, policies and procedures should be put in place to ensure all vendors are not included on the suspended and debarred listing.
The Organization concurs with the finding and acknowledges the need to improve its internal controls and procedures related to procurement and compliance with federal suspension and debarment requirements. To address this, the Organization will revise its procurement policies to ensure that all purchases of goods or services charged to federal awards --including those exceeding the $10,000 threshold --are subject to proper competitive procurement practices, in accordance with 45 CFR 75.329 and 2 CFR 180. Clear documentation requirements will be established and enforced for all procurement decisions, including price comparisons, vendor selection criteria, and justification for sole-source procurement, where applicable. Furthermore, the Organization will implement formal procedures to verify that all vendors are not suspended, debarred, or otherwise excluded from participation in federal programs. This will include performing and documenting verification against the System for Award Management (SAM.gov) prior to engaging vendors for federally funded procurements. All relevant staff will receive targeted training on these updated procurement and compliance procedures to ensure consistent application across the Organization. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization’s annual expenditure reporting did not agree to the underlying grant expenditure support. In addition, the Organization did not properly report certain information in its quarterly programmatic reports. Cause – The Organization did not have necessary internal controls to properly identify and report eligible grant expenditures. In addition, the Organization did not have controls in place to support amounts reported in quarterly programmatic reporting requirements. Effect or potential effect– The Organization incorrectly reported grant expenditures and programmatic statistics, such as total unique patients. Questioned Costs – None Context – A sample of one financial report was tested out of the total population of 2 financial reports. In addition, a sample of one special report was tested out of the total population of 4 special reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the financial and special reports were not accurately reported. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report.
Show full finding ▾Hide full finding ▴Opioid STR ALN No. 93.788 U.S. Department of Health and Human Services Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization’s annual expenditure reporting did not agree to the underlying grant expenditure support. In addition, the Organization did not properly report certain information in its quarterly programmatic reports. Cause – The Organization did not have necessary internal controls to properly identify and report eligible grant expenditures. In addition, the Organization did not have controls in place to support amounts reported in quarterly programmatic reporting requirements. Effect or potential effect– The Organization incorrectly reported grant expenditures and programmatic statistics, such as total unique patients. Questioned Costs – None Context – A sample of one financial report was tested out of the total population of 2 financial reports. In addition, a sample of one special report was tested out of the total population of 4 special reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the financial and special reports were not accurately reported. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report.
The Organization agrees with the finding and recognizes the importance of accurate financial and programmatic reporting in compliance with federal grant requirements. To address this issue, the Organization is strengthening its internal controls surrounding the preparation and review of all financial and programmatic reports submitted to granting agencies. Specifically, the finance department and program staff will implement a joint review process to reconcile reported expenditures and program statistics --such as patient counts --against underlying financial and operational records prior to submission. A standardized reporting checklist will be developed to ensure that all data points are verified for accuracy and that supporting documentation is retained and reviewed. In addition, staff responsible for grant reporting will receive training on federal reporting requirements, including those outlined in 45 CFR 75.342, to ensure consistency and compliance across all submissions. These steps will help ensure that all future reports accurately reflect grant expenditures and program outcomes, minimizing the risk of misreporting and ensuring transparency and accountability. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
COVID-19 Provider Relief Fund and American Rescue (ARP) Rural Distribution ALN No. 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116- 136, 134 Stat. 563 and Pub. L. No. 116- 139, 134 Stat. 622 and 623) and Reporting (45 CFR 75.342) Condition – The Organization was required to file a Period 2 and Period 3 Provider Relief Fund (PRF) reports during the year; however, did not maintain adequate documentation to support the other PRF expenses were attributable to coronavirus and/or had not been or were not eligible to be reimbursed by other sources. Questioned Costs – $261,607 calculated as the PRF amounts received by the Organization and included in Period 2 and Period 3 reporting. Context – The Organization was unable to provide adequate documentation to support the other PRF expenses had not been or were not eligible to be reimbursed by other sources. Effect – The Organization utilized PRF payments received on expenses that were not documented as attributable to coronavirus, were potentially reimbursed by other sources, and/or were not allowable in accordance with other guidance issued by HHS. Cause – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution is a new program with complex and evolving regulations and compliance requirements. Internal controls were not in place to ensure the Organization correctly applied the guidance. Identification as a repeat finding – Not a repeat finding Recommendation – Policies and procedures over allowable activities and federal grant reporting should be modified to ensure expenditures charged to grants are for activities allowed and federal grant reports are prepared using complete and accurate information.
Show full finding ▾Hide full finding ▴COVID-19 Provider Relief Fund and American Rescue (ARP) Rural Distribution ALN No. 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116- 136, 134 Stat. 563 and Pub. L. No. 116- 139, 134 Stat. 622 and 623) and Reporting (45 CFR 75.342) Condition – The Organization was required to file a Period 2 and Period 3 Provider Relief Fund (PRF) reports during the year; however, did not maintain adequate documentation to support the other PRF expenses were attributable to coronavirus and/or had not been or were not eligible to be reimbursed by other sources. Questioned Costs – $261,607 calculated as the PRF amounts received by the Organization and included in Period 2 and Period 3 reporting. Context – The Organization was unable to provide adequate documentation to support the other PRF expenses had not been or were not eligible to be reimbursed by other sources. Effect – The Organization utilized PRF payments received on expenses that were not documented as attributable to coronavirus, were potentially reimbursed by other sources, and/or were not allowable in accordance with other guidance issued by HHS. Cause – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution is a new program with complex and evolving regulations and compliance requirements. Internal controls were not in place to ensure the Organization correctly applied the guidance. Identification as a repeat finding – Not a repeat finding Recommendation – Policies and procedures over allowable activities and federal grant reporting should be modified to ensure expenditures charged to grants are for activities allowed and federal grant reports are prepared using complete and accurate information.
Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight by the Organizations parent company (Total Health Care, Inc.). Organization contact persons responsible for corrective action: Richard Greene, CFO Anticipated completion date: Correction action has been completed and is awaiting feedback from HRSA on how to submit updated lost revenue calculation.
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