EIN: 870288734
UEI: MUADG271HSL4
Data as of August 25, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on July 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 January 14, 2026 (224 days ago).
What is a management decision? →Significant Deficiency. As discussed in Finding 2024-001, approval/authorization for credit card expenditures are required before purchase. Some credit card transactions were discovered to not be approved during our audit procedures. Because of the failure to require approval from the proper level of management, fraudulent purchases could be made without knowledge of management. Procedures should be implemented requiring written approval of all expenditures.
Show full finding ▾Hide full finding ▴Significant Deficiency. As discussed in Finding 2024-001, approval/authorization for credit card expenditures are required before purchase. Some credit card transactions were discovered to not be approved during our audit procedures. Because of the failure to require approval from the proper level of management, fraudulent purchases could be made without knowledge of management. Procedures should be implemented requiring written approval of all expenditures.
Management intends to revise purchase order policies and procedures included in our finance policies and procedures to ensure that purchases receive prior approval before the purchase is made.
FAC accepted this audit on June 26, 2024 — management decision was due December 26, 2024.
The Organization did not properly monitor the total amount of expenditures on prescription and over-the counter medications. Effect of Condition: Exenditures of $13,477 in excess of the limitation were used on prescription or over-the-counter medications. Perspective information: The Organization appears to have properly monitored other spending limitations for this grant and this finding was determined to be an isolated instance. Recommendation: The Organization should establish policies and procedures to carefully review funding limitations on a regular basis so that they are properly followed. Views of Responsible Officials: Management has acknowledged the finding and repaid $13,477 in excess expenditures to the U.S. Department of Health and Human Services in February 2024.
Show full finding ▾Hide full finding ▴Criteria: The grant agreement specifies that no more than $30,000 is to be expended on prescription or over-the-counter medications during year one of the grant period. Condition: The Organization did not properly monitor the total amount of expenditures on prescription and over-the counter medications. Effect of Condition: Exenditures of $13,477 in excess of the limitation were used on prescription or over-the-counter medications. Perspective information: The Organization appears to have properly monitored other spending limitations for this grant and this finding was determined to be an isolated instance. Recommendation: The Organization should establish policies and procedures to carefully review funding limitations on a regular basis so that they are properly followed. Views of Responsible Officials: Management has acknowledged the finding and repaid $13,477 in excess expenditures to the U.S. Department of Health and Human Services in February 2024.
Corrective Action: In January 2024, the internal control structure for grant reimbursement documentation was modified. William Harrison, Controller, will review the cumulative grant reimbursement total for prescription drugs to ensure the total cumulative expenditures do not exceed the $30,000 limit for the grant period. Once reviewed by Mr. Harrison, the grant reimbursement requested will be presented to Judd Nielsen, Grant Evaluator, and Krista Byrd, Program Director, and to Maureen Collins, Executive Director, for their review and approval. In addition, when new grants or continuation funding awards are received, the Controller, William Harrison, Program Director, Krista Byrd, and Grant Evaluator, Judd Nielsen will meet to review all grant documentation to ensure everyone is aware of funding limitations.
FAC accepted this audit on July 13, 2022 — management decision was due January 13, 2023.
FINDING 2021-01 Out of Period Expenses PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: Costs must be incurred during the approved budget period. (Section 200.403(h) of 2 CFR Part 200 Subpart E). CONDITION: Two expenses tested were for pre-grant award activities incurred prior to the approved budget period. CAUSE: The expenses were for costs billed by the grant writer during the application process for the grant. Due to the costs being related to the grant, management considered such costs to be reimbursable by the grant. This was supported by the grant award that provides for such services to be funded by the grant. As a result, except for the out of period timing of the expenses, such costs would have been allowable. EFFECT: Unallowable expenses were incurred in the amount of $2,555. HOW THE QUESTIONED COSTS WERE COMPUTED: As noted above, the questioned costs were amounts paid for the out of period services. ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: These two expenses were the only charges paid to this service provider prior for services rendered prior to the budget period. REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The Organization should consider policies and procedures with respect to budget periods for grant awards. Additional documentation or approval forms should be incorporated which identify the budget period. Prior to approval for funding from the grant, the documentation should indicate that the cost was incurred in the applicable budget period. RESPONSE: See attached corrective action plan.
Show full finding ▾Hide full finding ▴FINDING 2021-01 Out of Period Expenses PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: Costs must be incurred during the approved budget period. (Section 200.403(h) of 2 CFR Part 200 Subpart E). CONDITION: Two expenses tested were for pre-grant award activities incurred prior to the approved budget period. CAUSE: The expenses were for costs billed by the grant writer during the application process for the grant. Due to the costs being related to the grant, management considered such costs to be reimbursable by the grant. This was supported by the grant award that provides for such services to be funded by the grant. As a result, except for the out of period timing of the expenses, such costs would have been allowable. EFFECT: Unallowable expenses were incurred in the amount of $2,555. HOW THE QUESTIONED COSTS WERE COMPUTED: As noted above, the questioned costs were amounts paid for the out of period services. ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: These two expenses were the only charges paid to this service provider prior for services rendered prior to the budget period. REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The Organization should consider policies and procedures with respect to budget periods for grant awards. Additional documentation or approval forms should be incorporated which identify the budget period. Prior to approval for funding from the grant, the documentation should indicate that the cost was incurred in the applicable budget period. RESPONSE: See attached corrective action plan.
FINDING 2021-01 Out of Period Expenses Corrective Action #1 - Project Reality will implement federal grant management policies and procedures and provide training to staff responsible for grant billing to ensure that out of period expenses are not charged to government grants (pursuant to Section 200.403(h) of 2 CFR Part 200 Subpart E. Response Responsible Parties ? The Outsourced CPA will draft the federal grant management policy and procedures which will be reviewed and approved by the Board of Directors. Corrective Action #2: Project Reality will ensure that expenses charged to federal grants are incurred during the approved budget period pursuant to Section 200.403(h) of 2 CFR Part 200 Subpart E). Response Responsible Parties ? The Senior Accountant will follow the federal grant management policies and procedures and will review expenses charged to a federal grant. In addition, grant revenue and expenses will be reviewed by the Outsourced CPA and reviewed and approved by the Executive Director.
FINDING 2021-02 Unallowable Costs PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: Costs must be adequately documented. (Section 200.403(g) of 2 CFR Part 200 Subpart E). CONDITION: Two expenses tested did not have receipts, invoices or other documentation to support the cost. CAUSE: The procedures requiring documented receipts were not adequately followed. EFFECT: Unallowable expenses were incurred in the amount of $49. HOW THE QUESTIONED COSTS WERE COMPUTED: The questioned costs were actual amounts paid. ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: In our sample of 60 items, these costs were the only costs without supporting documentation. REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The company should consider policies and procedures with respect to credit card usage. Additional training on the company credit card policy should be considered. Only costs that are documented in accordance with policy should be charged. To provide additional control, the person coding the expense to the program should verify and document that the cost is supported. Only such costs should be charged to the program. RESPONSE: See attached corrective action plan.
Show full finding ▾Hide full finding ▴FINDING 2021-02 Unallowable Costs PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: Costs must be adequately documented. (Section 200.403(g) of 2 CFR Part 200 Subpart E). CONDITION: Two expenses tested did not have receipts, invoices or other documentation to support the cost. CAUSE: The procedures requiring documented receipts were not adequately followed. EFFECT: Unallowable expenses were incurred in the amount of $49. HOW THE QUESTIONED COSTS WERE COMPUTED: The questioned costs were actual amounts paid. ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: In our sample of 60 items, these costs were the only costs without supporting documentation. REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The company should consider policies and procedures with respect to credit card usage. Additional training on the company credit card policy should be considered. Only costs that are documented in accordance with policy should be charged. To provide additional control, the person coding the expense to the program should verify and document that the cost is supported. Only such costs should be charged to the program. RESPONSE: See attached corrective action plan.
FINDING 2021-02 Unallowable Costs Corrective Action #1 - Project Reality will implement federal grant management policies and procedures and provide training to staff responsible for grant billing to ensure that costs are adequately documented pursuant to Section 200.403(g) of 2 CFR Part 200 Subpart E). Response Responsible Parties ? The Outsourced CPA will draft the federal grant management policy and procedures which will be reviewed and approved by the Board of Directors. Corrective Action #2 ? The Senior Accountant will follow the federal grant management policies and procedures and will ensure that all expenses being reimbursed, including credit card purchases, are properly documented and are allowable costs before being charged to a government grant. Grant revenue and expenses will be reviewed by the Outsourced CPA and reviewed and approved by the Executive Director. Response Responsible Parties ? The Senior Accountant, Outsourced CPA and Executive Director.
FINDING 2021-03 Depreciation Charged to Program PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: Direct costs are those costs that can be identified specifically with a particular final cost objective, such as a Federal award, or other internally or externally funded activity, or that can be directly assigned to such activities relatively easily with a high degree of accuracy. (Section 200.413(a) of 2 CFR Part 200 Subpart E) CONDITION: Starting in August 2021, depreciation was partially allocated to the program. The charges were made to the program as indirect charges. Although the grant provides for indirect costs, the Company has elected to use the deminimis rate of 10%. This additional indirect charge is not allowed under the grant award. CAUSE: The allocations were considered indirect charges and were allocated to the grant. EFFECT: Unallowable expenses were incurred in the amount of $1,837. HOW THE QUESTIONED COSTS WERE COMPUTED: The questioned costs were actual amounts charged to the grant. ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: In our sample of 60 items, we selected one monthly allocation. Per additional review of the charges, there were five similar charges to the program totaling $1,837. REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The company should consider policies and procedures with respect to charging depreciation, including reviewing contracts for allowability. RESPONSE: See attached corrective action plan.
Show full finding ▾Hide full finding ▴FINDING 2021-03 Depreciation Charged to Program PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: Direct costs are those costs that can be identified specifically with a particular final cost objective, such as a Federal award, or other internally or externally funded activity, or that can be directly assigned to such activities relatively easily with a high degree of accuracy. (Section 200.413(a) of 2 CFR Part 200 Subpart E) CONDITION: Starting in August 2021, depreciation was partially allocated to the program. The charges were made to the program as indirect charges. Although the grant provides for indirect costs, the Company has elected to use the deminimis rate of 10%. This additional indirect charge is not allowed under the grant award. CAUSE: The allocations were considered indirect charges and were allocated to the grant. EFFECT: Unallowable expenses were incurred in the amount of $1,837. HOW THE QUESTIONED COSTS WERE COMPUTED: The questioned costs were actual amounts charged to the grant. ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: In our sample of 60 items, we selected one monthly allocation. Per additional review of the charges, there were five similar charges to the program totaling $1,837. REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The company should consider policies and procedures with respect to charging depreciation, including reviewing contracts for allowability. RESPONSE: See attached corrective action plan.
FINDING 2021-03 Depreciation Charge to Program Corrective Action #1 - Project Reality will implement federal grant management policies and procedures and provide training to staff responsible for grant billing to ensure that costs are directly assigned to the grant activities pursuant to Section 200.413(a) of 2 CFR Part 200 Subpart E). Response Responsible Parties ? The Outsourced CPA will draft the federal grant management policy and procedures which will be reviewed and approved by the Board of Directors. Corrective Action #2 ? The Senior Accountant will follow the federal grant management policies and procedures and will ensure that allocated indirect charges are not charged to the federal grant. Grant revenue and expenses will be reviewed by the Outsourced CPA and reviewed and approved by the Executive Director. Response Responsible Parties ? The Senior Accountant, Outsourced CPA and Executive Director.
FINDING 2021-04 Policies Regarding Federal Expenditures PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: The financial accounting system must provide for: comparison of expenditures with budget amounts for each federal program, have written procedures with respect to section 200.305 (cash management), and have written procedures for determining the allowability of costs in accordance with Subpart D of Section 200 and the terms and conditions of the federal award. (Section 200.302(b)(5-7) of 2 CFR Part 200 Subpart D) CONDITION: There were no written policies in the financial accounting system to provide for: comparison of expenditures with budget amounts for each federal program, have written procedures with respect to section 200.305 (cash management), and have written procedures for determining the allowability of costs in accordance with Subpart D of Section 200 and the terms and conditions of the federal award. (Section 200.302(b)(5-7) of 2 CFR Part 200 Subpart D) CAUSE: The company was not aware that written controls and procedures over these matters are required for federal grant compliance. EFFECT: Non-compliance with 2 CFR Part 200 Subpart D. HOW THE QUESTIONED COSTS WERE COMPUTED: Not Applicable ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: Not Applicable REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The Organization should adopt written policies to address the requirements of 2 CFR Part 200 Subpart D. RESPONSE: See attached corrective action plan.
Show full finding ▾Hide full finding ▴FINDING 2021-04 Policies Regarding Federal Expenditures PROGRAM NAME: 93.829 Certified Community Behavioral Health Clinic - Integrated Care Program (CCBHC-ICP) Expansion CRITERIA: The financial accounting system must provide for: comparison of expenditures with budget amounts for each federal program, have written procedures with respect to section 200.305 (cash management), and have written procedures for determining the allowability of costs in accordance with Subpart D of Section 200 and the terms and conditions of the federal award. (Section 200.302(b)(5-7) of 2 CFR Part 200 Subpart D) CONDITION: There were no written policies in the financial accounting system to provide for: comparison of expenditures with budget amounts for each federal program, have written procedures with respect to section 200.305 (cash management), and have written procedures for determining the allowability of costs in accordance with Subpart D of Section 200 and the terms and conditions of the federal award. (Section 200.302(b)(5-7) of 2 CFR Part 200 Subpart D) CAUSE: The company was not aware that written controls and procedures over these matters are required for federal grant compliance. EFFECT: Non-compliance with 2 CFR Part 200 Subpart D. HOW THE QUESTIONED COSTS WERE COMPUTED: Not Applicable ISOLATED INSTANCE OR A SYSTEMIC PROBLEM: Not Applicable REPEAT FINDING? Not Applicable, this is the first audit in accordance with the Uniform Guidance. RECOMMENDATION: The Organization should adopt written policies to address the requirements of 2 CFR Part 200 Subpart D. RESPONSE: See attached corrective action plan.
FINDING 2021-04 Policies Regarding Federal Expenditures Corrective Action #1 - Project Reality will implement federal grant management policies and procedures and provide training to staff responsible for grant billing to ensure that there is a comparison of expenditures with budget amounts for each federal program. The policy and procedures will address section 200.305 (cash management), and have written procedures for determining eligible costs in accordance with Subpart D of Section 200 and the terms and conditions of the federal award pursuant to Section 200.302(b)(5-7) of 2 CFR Part 200 Subpart D). Response Responsible Parties ? The Outsourced CPA will draft the federal grant management policy and procedures which will be reviewed and approved by the Board of Directors. Corrective Action #2 ? A grant budget vs actual expense work paper will be created by the Outsourced CPA and utilized by the Senior Accountant to track the grant spend down by allowable expense classification. The first column will report the total grant budget by category. The next column will be the amount charged to the grant for each expense category for the month; the next column will report the amount of the total expenses for each budget category, and finally, a column for the remaining budget for each expense line item that needs to be spent before the grant expires. Response Responsible Parties ? The Outsourced CPA will provide the grant budget tracking work paper to Project Reality staff and the Senior Accountant will be the primary staff person utilizing the work paper. The Outsourced CPA will review the work paper each month and ensure it agrees to the general ledger and the federal expenditures are reported correctly in the SF-425 Federal Financial Reports.
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