EIN: 570672117
UEI: ZCZPKKLD37A1
Data as of August 24, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 19, 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 19, 2023 (1163 days ago).
What is a management decision? →The Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the year ended December 31, 2021, contained incorrect data for federal grants. The federal grants were overstated on Table 9E of the UDS report by approximately $1,861,000. Cause: The above exception resulted from errors in preparing Table 9E 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 systematic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that a system should be developed to ensure that total federal grants as reported in the Organization?s financial reporting system are reconciled to the UDS report. Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are reconciled from the financial reporting system to the UDS report. Contact Person: Jennifer Richardson, CFO Anticipated Date of Completion: January 31, 2023
Show full finding ▾Hide full finding ▴Finding: 2022-001 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, 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, 2021, contained incorrect data for federal grants. The federal grants were overstated on Table 9E of the UDS report by approximately $1,861,000. Cause: The above exception resulted from errors in preparing Table 9E 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 systematic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that a system should be developed to ensure that total federal grants as reported in the Organization?s financial reporting system are reconciled to the UDS report. Views of Responsible Officials: Management concurs. Efforts will be made to ensure that federal grants are reconciled from the financial reporting system to the UDS report. Contact Person: Jennifer Richardson, CFO Anticipated Date of Completion: January 31, 2023
In Finding 2022-001, it was reported that the Uniform Data System (UDS) report submitted to the U.S. Department of Health and Human Services (DHHS) for the year ended December 31, 2021, contained incorrect data for federal grants. The federal grants were overstated on Table 9E of the UDS report by approximately $1,861,000. Management recognizes the importance of complying with federal guidelines. In response to Finding 2022-001, procedures have been made to ensure that federal grants are reconciled from the financial reporting system to the UDS report. These procedures include a review checklist to ensure accuracy of the reporting.
FAC accepted this audit on November 7, 2021 — management decision was due May 7, 2022.
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. Cause: Controls over procurement were not properly implemented to verify that vendors are not suspended, debarred, or otherwise excluded from participating in federal programs before entering in transactions with them. 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. As a result, the Organization could enter into transactions with vendors that are suspended, debarred, or otherwise excluded from participating in federal programs. 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 and implement procedures to ensure that its policy regarding debarment searches is followed. 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 entering into transactions with them. Contact Person: Pam Davis, CEO Anticipated Date of Completion: December 31, 2021
Show full finding ▾Hide full finding ▴Finding: 2021-002 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 vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: Controls over procurement were not properly implemented to verify that vendors are not suspended, debarred, or otherwise excluded from participating in federal programs before entering in transactions with them. 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. As a result, the Organization could enter into transactions with vendors that are suspended, debarred, or otherwise excluded from participating in federal programs. 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 and implement procedures to ensure that its policy regarding debarment searches is followed. 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 entering into transactions with them. Contact Person: Pam Davis, CEO Anticipated Date of Completion: December 31, 2021
ln Finqi11g 2021-002, it was reported that the Organization did not verify that certi:iin vepdors were not suspended, debarred, or otqerwise excluded from participating in federal programs pefore entering into transactions with them. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2021-002, the Organization's financial policies and procedures have been updated to ensure that debarment searches are completed to verify that all vendors subject to debarme11t req?irements a-n? pot suspended, debarred, or otherwise excluded from pa1ticipi:iting in Federal programs bdore entering into transactions with them. LRMCs Financial Policies have been updated to i?clude: After the initial E-P?S searc?, contractors will be entered into the Compliatric Software which will automatically perform monthly EPLS searches, and send email notifications to the designee if the search results in an EPLS disbarment for verification. See attached approved financial policy "Screening Potential Contractors" section.
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