EIN: 830598989
UEI: FHEJFWMPDX59
Data as of August 25, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 14, 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 November 14, 2025 (285 days ago).
What is a management decision? →The Organization's procurement policies were not complete and the Organization did not follow the federal procurement standards which provides specific guidance including process and documentation requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326. Cause: The Organization’s procurement policies do not include the federal procurement requirements noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the required procurement documentation, provide for full and open competition, or provide support for limitation of such competition. Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects funded by federal sources. The Organization may have to pay back funds received for a project where federal funds were used for the procurement of products or services, but the required federal process was not met. Recommendation: The Organization should update their procurement policy to include all requirements as noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required processes. View of Responsible Officials: Management agrees with the finding and plans to update their procurement policy. Repeat Finding - 2022-001
Show full finding ▾Hide full finding ▴2023-001 – Procurement and Suspension and Debarment Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all grant numbers. Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. Condition: The Organization's procurement policies were not complete and the Organization did not follow the federal procurement standards which provides specific guidance including process and documentation requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326. Cause: The Organization’s procurement policies do not include the federal procurement requirements noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the required procurement documentation, provide for full and open competition, or provide support for limitation of such competition. Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects funded by federal sources. The Organization may have to pay back funds received for a project where federal funds were used for the procurement of products or services, but the required federal process was not met. Recommendation: The Organization should update their procurement policy to include all requirements as noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required processes. View of Responsible Officials: Management agrees with the finding and plans to update their procurement policy. Repeat Finding - 2022-001
Plan of Action: Provided policy F2.0 Materials Management, F2.01 Vendor Selection & Discount – currently being reviewed with the board for updates, and F2.03 Inventory and Supplies, which were not provided to the auditor due to the organization’s operational error in financial policy classification. Additionally, the F2.02 Capital and Equipment policy was drafted in 2021 will be reviewed and signed by the organizational board on Aug 26, 2024. The organization acknowledges that the procurement policy was not followed for one vendor procurement in 2022 due to an administrative error. This policy will be implemented and strictly followed immediately.
2022-001
Reported amounts were not reviewed and matched to the accounting records accurately prior to submission. Cause: The Organization does not have an adequate level of review in place to properly monitor the amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR section 200.328 of tracing amounts to records and verifying for accuracy and completeness. Effect: The Organization may not be eligible for future funding or might have to pay back federal funds received for not appropriately identifying and reporting their actual expenses. Questioned Costs: No costs were questioned as a result of this finding. Recommendation: The Organization should implement procedures for verifying accuracy and completeness prior to submission. View of Responsible Officials: Management agrees with the finding and plans to implement procedures for verifying accuracy and completeness prior to submission.
Show full finding ▾Hide full finding ▴2023-002 – Financial Reporting Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all grant numbers. Criteria: The Organization failed to follow the financial reporting requirements in 2 CFR section 200.328. The Organization did not trace the amounts reported to accounting records that support the audited financial statements and the schedule of expenditures of federal awards to verify accuracy and completeness. Condition: Reported amounts were not reviewed and matched to the accounting records accurately prior to submission. Cause: The Organization does not have an adequate level of review in place to properly monitor the amounts being reported for compliance. Actual amounts reported were inaccurate and did not match the actual expenses up to that point in time. The Organization did not follow the specific steps noted in 2 CFR section 200.328 of tracing amounts to records and verifying for accuracy and completeness. Effect: The Organization may not be eligible for future funding or might have to pay back federal funds received for not appropriately identifying and reporting their actual expenses. Questioned Costs: No costs were questioned as a result of this finding. Recommendation: The Organization should implement procedures for verifying accuracy and completeness prior to submission. View of Responsible Officials: Management agrees with the finding and plans to implement procedures for verifying accuracy and completeness prior to submission.
Plan of Action: To correct deficiencies in the preparation and submission of the SF-425 Federal Financial Report, the organization has established SOP F1.03: Submission and Recordkeeping of Federal Financial Reports (SF-425). This procedure outlines the steps for accurately completing the SF-425 using verified financial data, submitting it through the appropriate federal systems by required deadlines, and maintaining supporting documentation in compliance with federal recordkeeping standards. It applies to all staff involved in financial reporting on federally funded grants.
The Organization was unable to provide documentation to support the advanced draw calculation estimate or its approval by someone other than the individual who requested the draw for eleven of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested. Cause: The Organization does not have a consistent process in place to estimate the amount of advance draws for a 30-day period of needed funding, nor do they have a consistent process in place for the documentation of the review/approval of the advance draw by someone other than the individual who requests the funds. Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or staff could request funds without the proper approval. Questioned Costs: $460,000. Recommendation: The Organization should develop a clearly documented process and method to determine the amount of advance draw not to exceed a 30-day need. This process should include appropriate review, approval and documentation of the advance draw prior to requesting the funds. View of Responsible Officials: Management agrees with the finding and will develop a process and method to determine the appropriate calculation for the advance draw process including the proper review and approvals. Repeat Finding - 2022-003
Show full finding ▾Hide full finding ▴2023-003 – Cash Management Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all grant numbers. Criteria: Management is responsible for establishing and maintaining effective internal control over the advance payment requests related to federal awards. This includes review and approval for the advance draw from an individual other than the one requesting the draw, as well as support demonstrating that existing grant funds received were expended prior to additional funds being requested. Condition: The Organization was unable to provide documentation to support the advanced draw calculation estimate or its approval by someone other than the individual who requested the draw for eleven of the sixteen selections tested. The Organization was unable to support that existing grant funds were fully expended prior to submitting additional advance draw requests for eleven of the sixteen selections tested. Cause: The Organization does not have a consistent process in place to estimate the amount of advance draws for a 30-day period of needed funding, nor do they have a consistent process in place for the documentation of the review/approval of the advance draw by someone other than the individual who requests the funds. Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or staff could request funds without the proper approval. Questioned Costs: $460,000. Recommendation: The Organization should develop a clearly documented process and method to determine the amount of advance draw not to exceed a 30-day need. This process should include appropriate review, approval and documentation of the advance draw prior to requesting the funds. View of Responsible Officials: Management agrees with the finding and will develop a process and method to determine the appropriate calculation for the advance draw process including the proper review and approvals. Repeat Finding - 2022-003
Plan of Action: A New Cash Management Procedure was implemented on 5/5/24. We have also developed a tracking system in Microsoft Forms for the Project Director or Authorizing Officer to request and approve funds.
2022-003
FAC accepted this audit on May 15, 2024 — management decision was due November 15, 2024.
The Organization's procurement policies were not complete and the Organization did not follow the federal procurement standards which provides specific guidance including process and documentation requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326. Cause: The Organization’s procurement policies do not include the federal procurement requirements noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the required procurement documentation, provide for full and open competition, or provide support for limitation of such competition. Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects funded by federal sources. The Organization may have to pay back funds received for a project where federal funds were used for the procurement of products or services, but the required federal process was not met. Questioned Costs: No costs were questioned as a result of this finding. Recommendation: The Organization should update their procurement policy to include all requirements as noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required processes. View of Responsible Officials: Management agrees with the finding and plans to update their procurement policy.
Show full finding ▾Hide full finding ▴2022-001 – Procurement and Suspension and Debarment Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all grant numbers. Criteria: Non-federal entities must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. Condition: The Organization's procurement policies were not complete and the Organization did not follow the federal procurement standards which provides specific guidance including process and documentation requirements necessary to be in compliance as required by the 2 CFR sections 200.318 through 200.326. Cause: The Organization’s procurement policies do not include the federal procurement requirements noted at 2 CFR section 200.318 through 200.326. Additionally, the Organization did not maintain the required procurement documentation, provide for full and open competition, or provide support for limitation of such competition. Effect: Future procurement arrangements may not meet the federal guidelines necessary for projects funded by federal sources. The Organization may have to pay back funds received for a project where federal funds were used for the procurement of products or services, but the required federal process was not met. Questioned Costs: No costs were questioned as a result of this finding. Recommendation: The Organization should update their procurement policy to include all requirements as noted in 2 CFR sections 200.318-200.326 and ensure that all future agreements follow the required processes. View of Responsible Officials: Management agrees with the finding and plans to update their procurement policy.
Plan of Action: Provide policy F2.0 Materials Management, F2.01 Vendor Selection & Discount, and F2.03 Inventory and Supplies, which were not provided to the auditor due to the organization’s operational error in financial policy classification. Additionally, the F2.02 Capital and Equipment policy was drafted in 2021 but needs to be signed by the organizational board on May 24, 2024. The organization acknowledges that the procurement policy was not followed for one vendor procurement in 2022 due to an administrative error. Going forward this policy will be strictly followed. Date of implementation: F2 policies was implemented on 6/1/21 and updated on 6/1/2024
The Organization did not include required language in its communications surrounding federally funded projects as required by the Health Resources and Services Administration Grants Policy Bulletin Legislative Mandates in Grants Management for FY2022. Cause: The Organization was aware of the annual Bulletin, but as many of the other aspects did not apply, they overlooked the required federal funding language in the contract selected for testing. Effect: The Organization may not be eligible for future funding or might have to pay back federal funds received for costs not appropriately documented to support compliance with the HRSA Annual Grants Policy Bulletin requirements for federally funded projects. Questioned Costs: No costs were questioned as a result of this finding. Recommendation: Include language in the Organization's Grant Management Policy to include aspects of the Annual Policy Bulletin to ensure those in charge of communication are aware of the annual updates and requirements associated with projects funded with federal dollars View of Responsible Officials: Management agrees with the finding and will update the Grant Management Policy to include the applicable aspects of the Annual Policy Bulletin.
Show full finding ▾Hide full finding ▴2022-002 – Special Tests Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all grant numbers. Criteria: When issuing statements, press releases, requests for proposals, bid solicitations and other documents describing projects or programs funded in whole or in part with Federal money, all grantees receiving Federal funds included in this Act shall clearly state: (1) the percentage of the total costs of the program or project which will be financed with Federal money; (2) the dollar amount of Federal funds for the project or program; and (3) percentage and dollar amount of the total costs of the project or program that will be financed by nongovernmental sources. Condition: The Organization did not include required language in its communications surrounding federally funded projects as required by the Health Resources and Services Administration Grants Policy Bulletin Legislative Mandates in Grants Management for FY2022. Cause: The Organization was aware of the annual Bulletin, but as many of the other aspects did not apply, they overlooked the required federal funding language in the contract selected for testing. Effect: The Organization may not be eligible for future funding or might have to pay back federal funds received for costs not appropriately documented to support compliance with the HRSA Annual Grants Policy Bulletin requirements for federally funded projects. Questioned Costs: No costs were questioned as a result of this finding. Recommendation: Include language in the Organization's Grant Management Policy to include aspects of the Annual Policy Bulletin to ensure those in charge of communication are aware of the annual updates and requirements associated with projects funded with federal dollars View of Responsible Officials: Management agrees with the finding and will update the Grant Management Policy to include the applicable aspects of the Annual Policy Bulletin.
Plan of Action: The organization updated its F1.14 Federal Grants Management Policy on update 6/1/2023 and was approved by HRSA and reviewed and approved by the organizational board on 9/12/2023. The Annual Policy Bulletin will be reviewed and implemented annually. Date of implementation: 9/12/2023
The Organization was unable to provide documentation to support the advanced draw calculation estimate or its approval by someone other than the individual who requested the draw for 3 of the 11 selections tested. Cause: The Organization does not have a consistent process in place to estimate the amount of advance draws for a 30-day period of needed funding, nor do they have a consistent process in place for the documentation of the review/approval of the advance draw by someone other than the individual who requests the funds. Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or staff could request funds without the proper approval. Questioned Costs: $100,000 Recommendation: The Organization should develop a clearly documented process and method to determine the amount of advance draw not to exceed a 30-day need. This process should include appropriate review, approval and documentation of the advance draw prior to requesting the funds. View of Responsible Officials: Management agrees with the finding and will develop a process and method to determine the appropriate calculation for the advance draw process including the proper review and approvals.
Show full finding ▾Hide full finding ▴2022-003 – Cash Management Finding Type: Material Noncompliance; Material Weakness in Internal Control over Compliance Program: Rural Communities Opioid Response – Planning/Rural Health Outreach and Rural Network Development Program (AL# 93.912); U.S. Department of Health and Human Services; Direct award; all grant numbers. Criteria: Management is responsible for establishing and maintaining effective internal control over the advance payment requests related to federal awards. Condition: The Organization was unable to provide documentation to support the advanced draw calculation estimate or its approval by someone other than the individual who requested the draw for 3 of the 11 selections tested. Cause: The Organization does not have a consistent process in place to estimate the amount of advance draws for a 30-day period of needed funding, nor do they have a consistent process in place for the documentation of the review/approval of the advance draw by someone other than the individual who requests the funds. Effect: The Organization could advance draw an amount greater than their need for a 30-day period, or staff could request funds without the proper approval. Questioned Costs: $100,000 Recommendation: The Organization should develop a clearly documented process and method to determine the amount of advance draw not to exceed a 30-day need. This process should include appropriate review, approval and documentation of the advance draw prior to requesting the funds. View of Responsible Officials: Management agrees with the finding and will develop a process and method to determine the appropriate calculation for the advance draw process including the proper review and approvals.
Plan of Action: Drafted new procedure that will be implemented 5/15/24 and will develop a tracking system in Microsoft Forms for the Project Director or Authorizing Officer requesting and approval funds by 6/1/24. Date of implementation: 6/1/2024
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