EIN: 760622487
UEI: RKHRHEHZ5QM9
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 3, 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 April 3, 2023 (1242 days ago).
What is a management decision? →Criteria The Uniform Guidance in 2 CFR Section 200.303 requires that non-Federal entities receiving Federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal Statutes, regulations, and terms and conditions of the Federal Award. A non-Federal entity may charge to the Federal award only allowable costs incurred during the period of performance and any costs incurred before the Federal awarding agency or pass-through entity made the Federal award that were authorized by the Federal awarding agency or pass-through entity (2 CFR section 200.309). Condition During our testing, we noted that the Foundation included an expense from 2019 within the population of 2020 expenses charged to the grant. Questioned Cost: None Context Within the health center cluster, we identified one disbursement, in the amount of $432, which was related to goods/services received in 2019, but was included in the population of expenses for 2020. Although the cost was incurred during the grant budget period, it was not recorded in the proper year within the general ledger. Effect Without adequate controls in place to ensure costs are properly reviewed and captured within the appropriate periods, the Foundation could be out of compliance with the allowable costs compliance requirement. Cause The Foundation inappropriately allocated costs to the federal award based on the billing date for services, rather than the date at which those services were performed, and the expense incurred. Recommendation We recommend the Foundation enhance its processes and controls to ensure that only expenses incurred within the budget period be charged to the program. Views of responsible officials Management will implement a process to review and reconcile the federal award funds to ensure that only expenses incurred within the budget period are charged to the program.
Show full finding ▾Hide full finding ▴Criteria The Uniform Guidance in 2 CFR Section 200.303 requires that non-Federal entities receiving Federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal Statutes, regulations, and terms and conditions of the Federal Award. A non-Federal entity may charge to the Federal award only allowable costs incurred during the period of performance and any costs incurred before the Federal awarding agency or pass-through entity made the Federal award that were authorized by the Federal awarding agency or pass-through entity (2 CFR section 200.309). Condition During our testing, we noted that the Foundation included an expense from 2019 within the population of 2020 expenses charged to the grant. Questioned Cost: None Context Within the health center cluster, we identified one disbursement, in the amount of $432, which was related to goods/services received in 2019, but was included in the population of expenses for 2020. Although the cost was incurred during the grant budget period, it was not recorded in the proper year within the general ledger. Effect Without adequate controls in place to ensure costs are properly reviewed and captured within the appropriate periods, the Foundation could be out of compliance with the allowable costs compliance requirement. Cause The Foundation inappropriately allocated costs to the federal award based on the billing date for services, rather than the date at which those services were performed, and the expense incurred. Recommendation We recommend the Foundation enhance its processes and controls to ensure that only expenses incurred within the budget period be charged to the program. Views of responsible officials Management will implement a process to review and reconcile the federal award funds to ensure that only expenses incurred within the budget period are charged to the program.
Agree with finding. This finding occurred under unique circumstances. Throughout year 2020 and into year 2021, we had a very disgruntled employee who was responsible for entering Accounts Payable into the accounting system. Upon their departure and subsequent conversations with various vendors that had been communicating with only this disgruntled employee and sending invoices to this employee only, it was discovered that invoices had not been entered into the accounting system for approval and payment. In July 2021, additional policy and procedures were incorporated and communicated to ensure invoices are received, entered, approved and paid in a timely manner integrating multiple persons for all steps of the process. Completion Date: July 2021.
Criteria Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. (42 USC 254(k)(3)(G)(iii); 42 CFR sections 51c.303(f); and 42 CFR sections 56.303(f)). Condition During our testing we noted instances in which the federal poverty level calculations were done incorrectly. Questioned Cost None Context This condition occurred in thirteen of the twenty-five sliding fee patients selected for testing. Effect This condition to not impact or change the actual sliding fee category assigned to the patients selected for testing. However, incorrectly applying the federal poverty levels could cause the Foundation to incorrect apply its sliding fee scale policy. Cause The foundation did not properly calculate the patient?s applicable percentage of the federal poverty level when determining the applicable sliding fee determination. Recommendation We recommend the Foundation revisit its process for calculating and determining patient?s applicable percentage of the federal poverty levels to ensure that sliding fee discount categories are appropriately assigned. Views of responsible officials Management will implement a process to review applicable percentage to the federal poverty levels.
Show full finding ▾Hide full finding ▴Criteria Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. (42 USC 254(k)(3)(G)(iii); 42 CFR sections 51c.303(f); and 42 CFR sections 56.303(f)). Condition During our testing we noted instances in which the federal poverty level calculations were done incorrectly. Questioned Cost None Context This condition occurred in thirteen of the twenty-five sliding fee patients selected for testing. Effect This condition to not impact or change the actual sliding fee category assigned to the patients selected for testing. However, incorrectly applying the federal poverty levels could cause the Foundation to incorrect apply its sliding fee scale policy. Cause The foundation did not properly calculate the patient?s applicable percentage of the federal poverty level when determining the applicable sliding fee determination. Recommendation We recommend the Foundation revisit its process for calculating and determining patient?s applicable percentage of the federal poverty levels to ensure that sliding fee discount categories are appropriately assigned. Views of responsible officials Management will implement a process to review applicable percentage to the federal poverty levels.
Finding 2020-005 Special Tests and Provisions of Performance Agree with finding. We have incorporated and communicated changes to the policy and procedures to ensure all eligible patient?s federal poverty levels are calculated correctly and consistently and all appropriate documentation is maintained. This finding did not impact or change the actual sliding fee category for each patient. No costs were involved. Completion Date: September 2022.
FAC accepted this audit on November 29, 2020 — management decision was due May 29, 2021.
2019-02 Improper Use of Funds Federal Awarding Agency: U.S. Department of Health Resources & Services Administration Pass-Through Entity: Harris County Public Health & Environmental Services CFDA Number and Title: 93.914 Ryan White-Part A Applicable Compliance Component: Allowable Costs/Cost Principles. Condition During our testing of insurance coverage for the year ended December 31, 2019, we noted that the entity did not have adequate internal controls over use of federal funds and was not compliant with federal requirements to ensure that the organization would not benefit an individual. We found that there were 4 personal vehicles that received insurance coverage through the Organization. These vehicles were not owned by the Organization but by individual employees of the Organization. Thus, the insurance coverage benefitted individuals rather than the Organization itself. Criteria IRC 501(c)(3) states that a ?501(c) organization must not be organized or operated for the benefit of private interests?No part of the net earnings of a section 501 (c)(3) organization may inure to the benefit of any private shareholder or individual. A private shareholder or individual is a person having a personal and private interest in the activities of the organization.? Under 2 CFR 200.447(b)(4), ?costs of other insurance in connection with the general conduct of activities are allowable subject to the following limitations?[4]cost of insurance on the lives of trustees, officers, or other employees holding positions of similar responsibilities are allowable only to the extent that the insurance represents additional compensation. The cost of such insurance when the non-Federal entity is identified as the beneficiary is unallowable.? Cause The entity did not have a monitoring process in place to ensure the Organization?s funds were not used to benefit an individual or individuals. St. Hope Foundation had several vehicles listed on their insurance policy that is owned by staff and not the Organization. Effect Improper use of funds to potentially benefit an individual or individuals. Repeat Finding Not Applicable Questioned Costs Not determinable. Recommendation We recommend that St. Hope continues to strengthen the implementation of internal controls and compliance over insurance coverage to ensure the records are accurate and complete, and there are no funds being used to benefit one or more individuals. Additionally, we recommend that the management review on annual basis coverages and assets covered on the Organization?s insurance policies. Views of Responsible Officials of the Auditee Management agrees with the finding and has provided the corrective action plan following the Single Audit Report.
Show full finding ▾Hide full finding ▴2019-02 Improper Use of Funds Federal Awarding Agency: U.S. Department of Health Resources & Services Administration Pass-Through Entity: Harris County Public Health & Environmental Services CFDA Number and Title: 93.914 Ryan White-Part A Applicable Compliance Component: Allowable Costs/Cost Principles. Condition During our testing of insurance coverage for the year ended December 31, 2019, we noted that the entity did not have adequate internal controls over use of federal funds and was not compliant with federal requirements to ensure that the organization would not benefit an individual. We found that there were 4 personal vehicles that received insurance coverage through the Organization. These vehicles were not owned by the Organization but by individual employees of the Organization. Thus, the insurance coverage benefitted individuals rather than the Organization itself. Criteria IRC 501(c)(3) states that a ?501(c) organization must not be organized or operated for the benefit of private interests?No part of the net earnings of a section 501 (c)(3) organization may inure to the benefit of any private shareholder or individual. A private shareholder or individual is a person having a personal and private interest in the activities of the organization.? Under 2 CFR 200.447(b)(4), ?costs of other insurance in connection with the general conduct of activities are allowable subject to the following limitations?[4]cost of insurance on the lives of trustees, officers, or other employees holding positions of similar responsibilities are allowable only to the extent that the insurance represents additional compensation. The cost of such insurance when the non-Federal entity is identified as the beneficiary is unallowable.? Cause The entity did not have a monitoring process in place to ensure the Organization?s funds were not used to benefit an individual or individuals. St. Hope Foundation had several vehicles listed on their insurance policy that is owned by staff and not the Organization. Effect Improper use of funds to potentially benefit an individual or individuals. Repeat Finding Not Applicable Questioned Costs Not determinable. Recommendation We recommend that St. Hope continues to strengthen the implementation of internal controls and compliance over insurance coverage to ensure the records are accurate and complete, and there are no funds being used to benefit one or more individuals. Additionally, we recommend that the management review on annual basis coverages and assets covered on the Organization?s insurance policies. Views of Responsible Officials of the Auditee Management agrees with the finding and has provided the corrective action plan following the Single Audit Report.
St. Hope will continue to strengthen the implementation and monitoring of internal control and compliance over insurance coverage by completing an annual comprehensive insurance coverage examination with a professional insurance agent to be reviewed and presented to the Board of Directors for approval. An interim comprehensive review was completed by 8/21/2020 with the insurance contract being modified and updated. The changes will be submitted to the Board of Directors on December 10, 2020, for approval. The annual comprehensive insurance review and approval will be completed at insurance renewal time.
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