EIN: 560567980
UEI: EKKJNRWSKP74
Audited by: CLIFTONLARSONALLEN LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on April 5, 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 October 5, 2025 (329 days ago).
What is a management decision? →During our testing, we noted the Organization received reimbursement for the full amount of an expenditure, which included sales tax which they received a reimbursement for from the State. Questioned costs: None Context: During our testing of 29 samples, we noted 1 item for a $96 expenditure that incorrectly charged sales tax of $6.30 to the grant. Extrapolated to the entire population, an estimated $8.86 of expenditures would be incorrectly applied to the grant. Management has asserted this is the only instance of this issue. Cause: The Organization did not have adequate internal controls designed to properly determine the appropriate amounts to be submitted for reimbursement. Effect: Noncompliance with the federal requirements around the determination of an eligible expenditure. Recommendation: We recommend the Organization review the expenditures submitted to SAMHSA and ensure that there is no "double dipping' of sales taxes. Views of responsible officials: There is no disagreement with the audit finding..
Show full finding ▾Hide full finding ▴Federal Agency: Department of Health and Human Services Federal Program Name: Substance Abuse and Mental Health Services Projects of Regional and National Significance Assistance Listing Number: 93.243 Federal Award Identification Number and Year: 1H79SM087513-01 - 2024 Award Period: September 30, 2023 through September 29, 2027 Type of Finding: • Significant Deficiency in Internal Control over Compliance and Other Matters Criteria or specific requirement: Under 2 CRF 200.406, credits accruing to or received by the recipient of federal funding that relate to allowable costs must be credited to the Federal award as either a cost reduction or cash refund. Condition: During our testing, we noted the Organization received reimbursement for the full amount of an expenditure, which included sales tax which they received a reimbursement for from the State. Questioned costs: None Context: During our testing of 29 samples, we noted 1 item for a $96 expenditure that incorrectly charged sales tax of $6.30 to the grant. Extrapolated to the entire population, an estimated $8.86 of expenditures would be incorrectly applied to the grant. Management has asserted this is the only instance of this issue. Cause: The Organization did not have adequate internal controls designed to properly determine the appropriate amounts to be submitted for reimbursement. Effect: Noncompliance with the federal requirements around the determination of an eligible expenditure. Recommendation: We recommend the Organization review the expenditures submitted to SAMHSA and ensure that there is no "double dipping' of sales taxes. Views of responsible officials: There is no disagreement with the audit finding..
Recommendation: Under 2 CRF 200.406, credits accruing to or received by the recipient of federal funding that relate to allowable costs must be credited to the Federal award as either a cost reduction or cash refund. The Organization did not have adequate internal controls designed to properly determine the appropriate amounts to be submitted for reimbursement. We recommend the Organization review the expenditures submitted to SAMHSA and ensure that there is no "double dipping' of sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented a review process for all expenditures submitted to SAMHSA. The review process ensures that there is no “double dipping” of sales tax. Name(s) of the contact person(s) responsible for corrective action: Theresa Watters Planned completion date for corrective action plan: February 21, 2025
During our review of the grant expenditures, it was noted that budgeted amounts were charged to the grant instead of the actual costs incurred. This practice was observed in multiple instances, leading to discrepancies between the reported expenditures and the actual costs. Management did not review time and effort to make after-the-fact adjustments to the amounts charged to the grant. Questioned costs: None Context: The Organization had generally spent more than was funded for salaries and benefits under federal grants or would have expenses that would not be reimbursable under the program. Due to the actual salary amount expended exceeded the total grant budgeted amount, the Organization only charged the monthly budgeted amount instead of the actual amount expended. Cause: The incorrect charging of budgeted amounts instead of actual costs appears to be due to a lack of proper oversight and understanding of the grant requirements by the personnel responsible for financial reporting and grant management. Effect: Charging budgeted amounts instead of actual costs can result in non-compliance with grant requirements, potential disallowance of costs, and inaccurate financial reporting. This could also lead to financial penalties and affect the organization's ability to secure future funding. Recommendation: We recommend that the Organization establish a review process to ensure that all costs charged to the grant are based on actual expenditures and are properly documented. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: Department of Health and Human Services Federal Program Name: Substance Abuse and Mental Health Services Projects of Regional and National Significance Assistance Listing Number: 93.243 Federal Award Identification Number and Year: 1H79SM087513-01 - 2024 Award Period: September 30, 2023 through September 29, 2027 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: According to the grant agreement and 2 CFR 200.430(g), charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. In additions, according to 2 CFR 200.430(g)(1)(vii), budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that the system for establishing the estimates produces reasonable approximations of activity performed, significant changes in work activity are promptly identified and entered into the records, and the recipient’s system of internal controls includes processes to perform periodic after-the-fact reviews of interim charges made to a Federal awards based on budget estimates. All necessary adjustments must be made so that the final amount charges to the Federal award is accurate, allowable, and properly allocated. Condition: During our review of the grant expenditures, it was noted that budgeted amounts were charged to the grant instead of the actual costs incurred. This practice was observed in multiple instances, leading to discrepancies between the reported expenditures and the actual costs. Management did not review time and effort to make after-the-fact adjustments to the amounts charged to the grant. Questioned costs: None Context: The Organization had generally spent more than was funded for salaries and benefits under federal grants or would have expenses that would not be reimbursable under the program. Due to the actual salary amount expended exceeded the total grant budgeted amount, the Organization only charged the monthly budgeted amount instead of the actual amount expended. Cause: The incorrect charging of budgeted amounts instead of actual costs appears to be due to a lack of proper oversight and understanding of the grant requirements by the personnel responsible for financial reporting and grant management. Effect: Charging budgeted amounts instead of actual costs can result in non-compliance with grant requirements, potential disallowance of costs, and inaccurate financial reporting. This could also lead to financial penalties and affect the organization's ability to secure future funding. Recommendation: We recommend that the Organization establish a review process to ensure that all costs charged to the grant are based on actual expenditures and are properly documented. Views of responsible officials: There is no disagreement with the audit finding.
Recommendation: During our review of the grant expenditures, it was noted that budgeted amounts were charged to the grant instead of the actual costs incurred. This practice was observed in multiple instances, leading to discrepancies between the reported expenditures and the actual costs. Management did not review time and effort to make after-the-fact adjustments to the amounts charged to the grant. We recommend that the Organization establish a review process to ensure that all costs charged to the grant are based on actual expenditures and are properly documented Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has established a review process to ensure that all costs charged to the grant are based on actual expenditures and are properly documented. Name(s) of the contact person(s) responsible for corrective action: Theresa Watters Planned completion date for corrective action plan: February 21, 2025
During our review of the organization's procurement processes, it was noted that the organization does not have a procurement policy that complies with federal requirements. Specifically, the policy does not address key elements such as competition, cost or price analysis, and documentation requirements as outlined in federal regulations. Questioned costs: None Context: Policies exist, but do not meet requirements. There are no requirements to retain documentation related to comparison or analysis prior to purchase or procurement. Cause: The absence of a compliant procurement policy appears to be due to a lack of awareness of the specific federal requirements and the absence of a formal process to review and update organizational policies to ensure compliance. Effect: Without a procurement policy that complies with federal requirements, the organization is at risk of non-compliance with grant conditions, which could lead to questioned costs, potential disallowance of expenditures, and jeopardize future funding opportunities. Recommendation: We recommend that the Organization develop and implement a procurement policy that complies with federal requirements, including provisions for competition, cost or price analysis, and proper documentation. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: Department of Health and Human Services Federal Program Name: Substance Abuse and Mental Health Services Projects of Regional and National Significance Assistance Listing Number: 93.243 Federal Award Identification Number and Year: 1H79SM087513-01 - 2024 Award Period: September 30, 2023 through September 29, 2027 Type of Finding: • Other Matters Criteria or specific requirement: According to 2 CFR 200.318, non-federal entities must have and use documented procurement procedures that reflect applicable state and local laws and regulations, and conform to federal law and the standards identified in 2 CFR 200.318 through 2 CFR 200.327. Condition: During our review of the organization's procurement processes, it was noted that the organization does not have a procurement policy that complies with federal requirements. Specifically, the policy does not address key elements such as competition, cost or price analysis, and documentation requirements as outlined in federal regulations. Questioned costs: None Context: Policies exist, but do not meet requirements. There are no requirements to retain documentation related to comparison or analysis prior to purchase or procurement. Cause: The absence of a compliant procurement policy appears to be due to a lack of awareness of the specific federal requirements and the absence of a formal process to review and update organizational policies to ensure compliance. Effect: Without a procurement policy that complies with federal requirements, the organization is at risk of non-compliance with grant conditions, which could lead to questioned costs, potential disallowance of expenditures, and jeopardize future funding opportunities. Recommendation: We recommend that the Organization develop and implement a procurement policy that complies with federal requirements, including provisions for competition, cost or price analysis, and proper documentation. Views of responsible officials: There is no disagreement with the audit finding.
Recommendation: During our review of the organization's procurement processes, it was noted that the organization does not have a procurement policy that complies with federal requirements. Specifically, the policy does not address key elements such as competition, cost or price analysis, and documentation requirements as outlined in federal regulations. We recommend that the Organization develop and implement a procurement policy that complies with federal requirements, including provisions for competition, cost or price analysis, and proper documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has reviewed the federal law and standards identified in 2 CFR 200.318 through 2 CFR 200.327. A procurement policy that aligns with these federal requirements is currently being developed. The policy is expected to be adopted and in place in the coming months. Name(s) of the contact person(s) responsible for corrective action: Angela Woods Planned completion date for corrective action plan: June 2, 2025
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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