EIN: 840474717
UEI: G7K7HMWE8E78
Audit also covers 2 related EINs: 311532716, 841182066 · unlinked EINs have no separate FAC filing
Audited by: Forvis Mazars, 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 May 23, 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 23, 2026 (85 days from today).
What is a management decision? →FAC accepted this audit on July 31, 2025 — management decision was due January 31, 2026.
FAC accepted this audit on November 25, 2024 — management decision was due May 25, 2025.
During our procurement testing, we identified that the Organization did not obtain price quotes related to the purchase of $193,378 which fell within the small purchases threshold. Questioned Costs: $193,378 Context: We tested the Organizations one small purchase procurement which occurred during fiscal year 2023 in the amount of $193,978 and noted the above issue. A nonstatistical sampling methodology was used to select the sample. Effect: The Organization was not in compliance with its procurement policies and the Uniform Guidance. Cause: The Organization did not have adequate documentation to support the Organizations procurement decisions. Identification as a repeat finding: Not a repeat finding Recommendation: We recommend that the Organization follow its procurement procedures for the acquisition of property or services as required under a Federal award or sub-award. Views of responsible officials: The Organization agrees with the finding. See separate report for planned corrective actions.
Show full finding ▾Hide full finding ▴Finding: Procurement Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds U.S. Department of The Treasury pass through from Jefferson County and Signal Behavioral Health Network Award Year: 2023 Award Number: Not Provided Criteria: In accordance with 2 CFR 200.318, non-Federal entities must have and use documented procurement procedures, consistent with State and local regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity’s documented procurement procedures must conform to the procurement standards identified in 2 CFR 200.317 through 200.327. The Organizations procurement policy requires for Small purchases between $10,000 and $250,000. Competitive price quotes must be obtained to allow for full and open competition. a. A written solicitation including specs will be prepared and prices (might also include quality, delivery, geographical preference) obtained from multiple sources (preferably three or more) either by providing specs to the vendors or researching vendor prices (ex. internet search, vendor pricing list, verbal quotes). b. The price quotes will remain confidential before the award. c. Quotes will be evaluated by the business office and awarded based on price and the factors identified in the original request for quotes. d. Ensure all vendors receive the same information about the products or services and any special need that could affect the price. e. Check vendors for federal disbarment or suspension. Condition: During our procurement testing, we identified that the Organization did not obtain price quotes related to the purchase of $193,378 which fell within the small purchases threshold. Questioned Costs: $193,378 Context: We tested the Organizations one small purchase procurement which occurred during fiscal year 2023 in the amount of $193,978 and noted the above issue. A nonstatistical sampling methodology was used to select the sample. Effect: The Organization was not in compliance with its procurement policies and the Uniform Guidance. Cause: The Organization did not have adequate documentation to support the Organizations procurement decisions. Identification as a repeat finding: Not a repeat finding Recommendation: We recommend that the Organization follow its procurement procedures for the acquisition of property or services as required under a Federal award or sub-award. Views of responsible officials: The Organization agrees with the finding. See separate report for planned corrective actions.
CLIENT PLANNED ACTION: When a new federally funded construction project or purchase is in the planning stage that is in the price range of $10,000 to $250,000(a small purchase), the Director of Facilities and/or the Purchasing agent will send out solicitations including specs via letter, email or by phone to multiple vendors. They may also look up vendor pricing on the internet. After the quotes are received, they will forward them to the CFO or Director of Finance who will then evaluate the quotes and decide on a vendor. Before the vendor is notified, the business office staff will check SAM.gov for federal disbarment or suspension. The SAM.gov verification will be saved in the accounting vendor files. Copies of the quotes will also be filed in the accounting office. CLIENT RESPONSIBLE PARTY: Name of Contact Person: David A. Goff, MBA Vice President of Administration and Chief Financial Officer. 4851 Independence Street, Wheat Ridge, CO 80033. 303-432-5164, Davidg@jcmh.org COMPLETION DATE: 9/1/2024
FAC accepted this audit on March 8, 2023 — management decision was due September 8, 2023.
During our review of the Period 3 report submitted, we noted the Organization included revenue items that should not have been included in the lost revenue calculation and indicated that the calculation was under Option 2 but should have reported under Option 3. In addition, actual revenues and budgeted revenues included in the lost revenue calculation did not agree to the underlying accounting records and approved budgets. Questioned Costs: Unknown Context: Pharmacy revenue and grant revenue should not have been included in the lost revenue calculation and Option 2 required a budget to be approved by March 27, 2020 and not all of the budgets utilized in the reporting of Period 3 were approved by that deadline. The lost revenue calculation included actual and budgeted revenue amounts that did not agree to the underlying accounting records and approved budgets. Effect: The federal government relies on the information reported in the Health Resources and Services Administration (HRSA) to be accurate for monitoring purposes. Errors were made in reporting quarterly total revenue/net charges from patient care for each year, 2020, 2021, and 2022. and by selecting the incorrect option, the Organization did not submit the required narrative information to HRSA. Cause: The Organization did not have adequate internal controls in place to identify revenue amounts that should not have been included in the lost revenue calculation, that option 3 should have been selected for reporting and that the actual and budgeted revenues reported did not agree to the underlying accounting records and approved budgets. Identification as a repeat finding: Not a repeat finding. Recommendation: The Organization should continue to improve their understanding of the guidance related to this type of reporting and implement additional controls over future reporting periods to help ensure guidance is followed. Views of responsible officials: The Organization agrees with the finding. See separate report for planned corrective actions.
Show full finding ▾Hide full finding ▴Criteria: Reporting (45 CFR 75.342) and 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). The Provider Relief Fund (PRF) was established in the Coronavirus Aid, Relief, and Economic Security Act (CARES Act, P.L. 116-136) to reimburse, through grants or other mechanisms, eligible health care providers for increased expenses or lost revenue attributable to Coronavirus Disease 2019 (COVID-19). Entities that receive more than $10,000 (either one time or in the aggregate) are required to report the uses of their funds, including the lost revenue reimbursement and documentation of how the lost revenue was calculated. In addition, the Organization is required to implement and maintain internal controls over financial reporting. Condition: During our review of the Period 3 report submitted, we noted the Organization included revenue items that should not have been included in the lost revenue calculation and indicated that the calculation was under Option 2 but should have reported under Option 3. In addition, actual revenues and budgeted revenues included in the lost revenue calculation did not agree to the underlying accounting records and approved budgets. Questioned Costs: Unknown Context: Pharmacy revenue and grant revenue should not have been included in the lost revenue calculation and Option 2 required a budget to be approved by March 27, 2020 and not all of the budgets utilized in the reporting of Period 3 were approved by that deadline. The lost revenue calculation included actual and budgeted revenue amounts that did not agree to the underlying accounting records and approved budgets. Effect: The federal government relies on the information reported in the Health Resources and Services Administration (HRSA) to be accurate for monitoring purposes. Errors were made in reporting quarterly total revenue/net charges from patient care for each year, 2020, 2021, and 2022. and by selecting the incorrect option, the Organization did not submit the required narrative information to HRSA. Cause: The Organization did not have adequate internal controls in place to identify revenue amounts that should not have been included in the lost revenue calculation, that option 3 should have been selected for reporting and that the actual and budgeted revenues reported did not agree to the underlying accounting records and approved budgets. Identification as a repeat finding: Not a repeat finding. Recommendation: The Organization should continue to improve their understanding of the guidance related to this type of reporting and implement additional controls over future reporting periods to help ensure guidance is followed. Views of responsible officials: The Organization agrees with the finding. See separate report for planned corrective actions.
As stated in the audit findings, there were errors made in reporting lost revenue, which included pharmacy and grant revenue. Jefferson Center agrees there were errors made and are providing a solution for the corrective action plan. It?s every important for Jefferson Center for Mental Health to report accurately and timely information. All future reporting and correspondence on provider relief funding will be reviewed by multiple fiscal staff, including the Controller, Director of Finance and the Chief Financial Officer. Having multiple qualified staff to review and agree that the correct procedures have been followed and that the information being reported is accurate, will ultimately meet our goal of reporting 100% accurate information. In the future, the Controller will prepare the reporting information, the Director of Finance will assist the Controller in reviewing the reporting guidelines and timelines as well as assist with populating the reports with the correct data. The Chief Financial Officer will review the reports and data sources to ensure that we follow the correct reporting guidelines. Jefferson Center will also make sure that we have the latest Post-payment Notice of Reporting Requirements from the HRSA website to ensure we?re aware of the latest reporting requirements. Projected Completion Date: February 15, 2023 CLIENT RESPONSIBLE PARTY: Name of Contact Person: David A. Goff, MBA Vice President of Administration and Chief Financial Officer. 4851 Independence Street, Wheat Ridge, CO 80033. 303-432-5164, Davidg@jcmh.org
FAC accepted this audit on May 31, 2022 — management decision was due December 1, 2022.
FAC accepted this audit on June 14, 2021 — management decision was due December 14, 2021.
FAC accepted this audit on November 19, 2019 — management decision was due May 19, 2020.
FAC accepted this audit on January 7, 2019 — management decision was due July 7, 2019.
FAC accepted this audit on December 18, 2017 — management decision was due June 18, 2018.
FAC accepted this audit on January 29, 2017 — management decision was due July 29, 2017.
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