EIN: 870726056
UEI: J683B73JFQL3
Audited by: Summit West CPA Group, P.C.
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 14, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on August 25, 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 February 25, 2027 (163 days from today).
What is a management decision? →FINDING 2025-004 – Material Weakness in Internal Controls over Compliance Federal Agency: U.S. Department of Health and Human Services Federal Program: Maternal Infant and Early Childhood Home Visiting (MIECHV) Assistance Listing Number: 93.870 Compliance Requirements: Activities Allowed or Unallowed / Allowable Costs / Procurement and Suspension and Debarment / Reporting Type of Finding: Material Weakness in Internal Control Over Compliance Criteria The Uniform Guidance requires non-federal entities receiving federal awards to establish and maintain effective internal control over federal awards that provides reasonable assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Under 2 CFR § 200.303, the auditee is required to establish and maintain effective internal controls over federal awards that provide reasonable assurance that the auditee is managing the award in compliance with applicable requirements. In addition, 2 CFR § 200.516 requires the auditor to report significant deficiencies and/or material weaknesses in internal control over major programs as audit findings in the schedule of findings and questioned costs. Condition During our audit of the federal program identified above, we noted that internal controls over compliance were not designed and/or operating effectively to allow the auditor to rely on those controls for purposes of performing the Single Audit. Specifically, management was unable to provide sufficient evidence that key controls over activities allowed or unallowed, allowable costs, procurement and suspension and debarment, and reporting existed or were consistently performed, reviewed, and documented. Examples noted included the following: • Approval and review controls were not consistently documented. • Supporting documentation was not consistently retained to demonstrate compliance with program requirements. • Control activities were performed informally and were not supported by evidence of review. • Duties related to preparation, approval, and review of compliance information were not adequately segregated. • Management’s monitoring of compliance activities was not sufficiently documented. As a result, we were unable to rely on internal controls over compliance and performed additional substantive procedures to obtain sufficient appropriate audit evidence regarding the entity’s compliance with the applicable federal program requirements. Cause The condition appears to have resulted from insufficient formalization and documentation of internal control procedures over federal program compliance. While certain review or approval procedures may have been performed, the entity did not maintain adequate documentation to demonstrate that those controls were performed timely, consistently, and by appropriate personnel. In addition, the entity experienced significant turn over in external bookkeeping firms and management during the fiscal year. Additionally, they undertook an accounting software transition that resulted in significant delays in timely recording of accounting transactions and monitoring of controls. Effect or Potential Effect When internal controls over compliance are not adequately designed, implemented, or documented, there is an increased risk that noncompliance with federal statutes, regulations, or award terms and conditions could occur and not be prevented, detected, or corrected in a timely manner. Although our substantive audit procedures did not identify material noncompliance with the applicable compliance requirements, the lack of effective and documented internal controls limited the auditor’s ability to rely on those controls and increased the risk of errors or noncompliance related to the federal program. Questioned Costs None noted Context The federal program identified above was audited as a major program for the year ended June 30, 2025. During our audit procedures, we selected samples related to payroll disbursements, direct grant expenditures, and reporting for grant reimbursements and evaluated whether internal controls over compliance were designed and operating effectively. Based on the procedures performed, we determined that the entity did not maintain sufficient evidence of control performance to support reliance on internal controls over compliance for the applicable compliance requirement. Repeat Finding This is not a repeat finding. Sampling Method Not applicable Recommendation We recommend that management strengthen its internal controls over federal program compliance by implementing formal written procedures that identify the specific controls to be performed, the personnel responsible for performing and reviewing those controls, and the documentation required to evidence control performance. At a minimum, management should: • Develop written policies and procedures for each applicable compliance requirement. • Identify key controls over compliance and assign responsibility for performance and review. • Maintain documentation evidencing review, approval, and monitoring activities. • Provide training to program and finance personnel regarding federal compliance requirements and Single Audit documentation expectations. • Periodically monitor compliance activities to ensure controls are operating as designed. • Design controls that limit the risk of management override.
Show full finding ▾Hide full finding ▴FINDING 2025-004 – Material Weakness in Internal Controls over Compliance Federal Agency: U.S. Department of Health and Human Services Federal Program: Maternal Infant and Early Childhood Home Visiting (MIECHV) Assistance Listing Number: 93.870 Compliance Requirements: Activities Allowed or Unallowed / Allowable Costs / Procurement and Suspension and Debarment / Reporting Type of Finding: Material Weakness in Internal Control Over Compliance Criteria The Uniform Guidance requires non-federal entities receiving federal awards to establish and maintain effective internal control over federal awards that provides reasonable assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Under 2 CFR § 200.303, the auditee is required to establish and maintain effective internal controls over federal awards that provide reasonable assurance that the auditee is managing the award in compliance with applicable requirements. In addition, 2 CFR § 200.516 requires the auditor to report significant deficiencies and/or material weaknesses in internal control over major programs as audit findings in the schedule of findings and questioned costs. Condition During our audit of the federal program identified above, we noted that internal controls over compliance were not designed and/or operating effectively to allow the auditor to rely on those controls for purposes of performing the Single Audit. Specifically, management was unable to provide sufficient evidence that key controls over activities allowed or unallowed, allowable costs, procurement and suspension and debarment, and reporting existed or were consistently performed, reviewed, and documented. Examples noted included the following: • Approval and review controls were not consistently documented. • Supporting documentation was not consistently retained to demonstrate compliance with program requirements. • Control activities were performed informally and were not supported by evidence of review. • Duties related to preparation, approval, and review of compliance information were not adequately segregated. • Management’s monitoring of compliance activities was not sufficiently documented. As a result, we were unable to rely on internal controls over compliance and performed additional substantive procedures to obtain sufficient appropriate audit evidence regarding the entity’s compliance with the applicable federal program requirements. Cause The condition appears to have resulted from insufficient formalization and documentation of internal control procedures over federal program compliance. While certain review or approval procedures may have been performed, the entity did not maintain adequate documentation to demonstrate that those controls were performed timely, consistently, and by appropriate personnel. In addition, the entity experienced significant turn over in external bookkeeping firms and management during the fiscal year. Additionally, they undertook an accounting software transition that resulted in significant delays in timely recording of accounting transactions and monitoring of controls. Effect or Potential Effect When internal controls over compliance are not adequately designed, implemented, or documented, there is an increased risk that noncompliance with federal statutes, regulations, or award terms and conditions could occur and not be prevented, detected, or corrected in a timely manner. Although our substantive audit procedures did not identify material noncompliance with the applicable compliance requirements, the lack of effective and documented internal controls limited the auditor’s ability to rely on those controls and increased the risk of errors or noncompliance related to the federal program. Questioned Costs None noted Context The federal program identified above was audited as a major program for the year ended June 30, 2025. During our audit procedures, we selected samples related to payroll disbursements, direct grant expenditures, and reporting for grant reimbursements and evaluated whether internal controls over compliance were designed and operating effectively. Based on the procedures performed, we determined that the entity did not maintain sufficient evidence of control performance to support reliance on internal controls over compliance for the applicable compliance requirement. Repeat Finding This is not a repeat finding. Sampling Method Not applicable Recommendation We recommend that management strengthen its internal controls over federal program compliance by implementing formal written procedures that identify the specific controls to be performed, the personnel responsible for performing and reviewing those controls, and the documentation required to evidence control performance. At a minimum, management should: • Develop written policies and procedures for each applicable compliance requirement. • Identify key controls over compliance and assign responsibility for performance and review. • Maintain documentation evidencing review, approval, and monitoring activities. • Provide training to program and finance personnel regarding federal compliance requirements and Single Audit documentation expectations. • Periodically monitor compliance activities to ensure controls are operating as designed. • Design controls that limit the risk of management override.
Response and Views of Responsible Officials Management acknowledges the finding related to the design and operating effectiveness of internal controls over compliance for the MIECHV program. While key review processes were generally in place, the organization recognizes that controls were not consistently documented or demonstrated during the audit period. In addition, documentation supporting expenditure approvals, grant coding, reimbursement preparation, supervisory review, and retention of supporting records was not consistently maintained. As a result, the auditors were unable to rely on the organization's internal controls to reduce the risk of noncompliance. The organization has taken the following corrective actions: • Adopted comprehensive Financial Policies and Procedures and Accounting Policies that clearly define internal controls over purchasing, cash disbursements, payroll, grant management, documentation retention, segregation of duties, supervisory review, and financial reporting. • Implemented written procedures outlining the authorization, coding, allocation, reimbursement, and documentation requirements for grant-funded expenditures. • Adopted a formal Cost Allocation Plan that documents the methodology for allocating shared costs and grant expenditures. • Assigned responsibility for independent review of reimbursement requests prior to submission. Reimbursement requests are now prepared by program management and reviewed by the internal bookkeeper before submission whenever practicable. • Established standardized documentation requirements to retain supporting invoices, approvals, allocation documentation, reimbursement support, and evidence of supervisory review within organized grant files. • Established procedures requiring documentation of management review through signatures, initials, electronic approvals, or other evidence demonstrating that required reviews were completed. To further strengthen internal controls and ensure continued compliance, the organization will: • Develop standardized internal review checklists for reimbursement requests and other key grant compliance activities to document preparation, supervisory review, and approval. • Conduct periodic internal monitoring to verify that established procedures are operating consistently and that supporting documentation is complete. • Provide training to staff responsible for grant administration and financial management regarding internal control responsibilities, documentation expectations, and federal compliance requirements. • Incorporate periodic management review of grant files to verify that expenditures, approvals, reimbursement documentation, and supporting records are complete and retained in accordance with organizational policies. Responsible Official: Josie Brittain Anticipated Completion Date: September 30, 2026
FINDING 2025-005 – Noncompliance with Procurement and Suspension and Debarment Requirements Federal Agency: U.S. Department of Health and Human Services Federal Program: Maternal Infant and Early Childhood Home Visiting (MIECHV) Assistance Listing Number: 93.870 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control Over Compliance and Instance of Noncompliance Criteria The Uniform Guidance requires recipients and subrecipients to maintain and use documented procurement procedures for procurement transactions under a federal award or subaward, including the acquisition of property or services. These documented procurement procedures must be consistent with applicable state, local, and tribal laws and regulations, as well as the federal procurement standards included in 2 CFR §§ 200.317 through 200.327. In addition, recipients and subrecipients are required to establish and maintain effective internal control over federal awards to provide reasonable assurance that the federal award is managed in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Audit findings are required to be reported for significant deficiencies or material weaknesses in internal control over major programs and for material noncompliance related to major programs. Condition During our audit of the federal program identified above, we noted the entity did not have documented procurement procedures in place as required by the applicable Procurement and Suspension and Debarment compliance requirement. Specifically, management was unable to provide written procurement policies and procedures addressing procurement transactions charged to federal awards. The entity’s procedures did not document the required procurement methods, approval requirements, documentation standards, conflict-of-interest considerations, or suspension and debarment verification procedures applicable to federally funded purchases. As a result, the entity was not in compliance with the requirement to maintain and use documented procurement procedures for procurement transactions under a federal award. Cause The condition appears to have resulted from the entity not formally updating or adopting written procurement procedures to address federal procurement requirements. While management may have followed informal purchasing practices, those practices were not formally documented, approved, or consistently communicated to personnel responsible for procurement activities under federal awards. Additionally, responsible personnel may not have been sufficiently familiar with the federal procurement documentation requirements applicable to federal awards. Effect or Potential Effect Failure to maintain documented procurement procedures increases the risk that procurement transactions charged to federal awards may not be performed in accordance with federal requirements. This could result in purchases that are not properly authorized, not adequately supported, not subject to required competition, or made with vendors that should have been excluded from participation in federal programs. The lack of documented procedures also increases the risk that suspension and debarment verification procedures may not be consistently performed or retained, which could result in federal funds being used for transactions with suspended, debarred, or otherwise excluded parties. Although no questioned costs were identified as a result of this finding, the absence of documented procurement procedures represents noncompliance with federal procurement requirements and a deficiency in internal control over compliance. Questioned Costs None noted Context The federal program was audited as a major program for the year ended June 30, 2025. During our procedures over the Procurement and Suspension and Debarment compliance requirement, we requested the entity’s written procurement policies and procedures applicable to federal awards. Management was unable to provide documented procurement procedures that addressed the required federal procurement standards. Accordingly, the entity did not demonstrate compliance with the requirement to maintain and use documented procurement procedures for federally funded procurement transactions. Repeat Finding This is not a repeat finding. Sampling Method Not applicable Recommendation We recommend management develop, formally approve, and implement written procurement policies and procedures applicable to federal awards. At a minimum, the procedures should address: • The procurement methods allowed under federal requirements. • Required documentation for procurement decisions. • Approval levels and responsibilities for federally funded purchases. • Competition and price/cost analysis requirements, when applicable. • Conflict-of-interest standards for employees involved in procurement. • Required suspension and debarment verification procedures. • Documentation retention requirements for procurement files. • Periodic review procedures to ensure procurement practices comply with federal requirements. We also recommend management provide training to employees responsible for initiating, approving, and documenting procurement transactions charged to federal awards.
Show full finding ▾Hide full finding ▴FINDING 2025-005 – Noncompliance with Procurement and Suspension and Debarment Requirements Federal Agency: U.S. Department of Health and Human Services Federal Program: Maternal Infant and Early Childhood Home Visiting (MIECHV) Assistance Listing Number: 93.870 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control Over Compliance and Instance of Noncompliance Criteria The Uniform Guidance requires recipients and subrecipients to maintain and use documented procurement procedures for procurement transactions under a federal award or subaward, including the acquisition of property or services. These documented procurement procedures must be consistent with applicable state, local, and tribal laws and regulations, as well as the federal procurement standards included in 2 CFR §§ 200.317 through 200.327. In addition, recipients and subrecipients are required to establish and maintain effective internal control over federal awards to provide reasonable assurance that the federal award is managed in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Audit findings are required to be reported for significant deficiencies or material weaknesses in internal control over major programs and for material noncompliance related to major programs. Condition During our audit of the federal program identified above, we noted the entity did not have documented procurement procedures in place as required by the applicable Procurement and Suspension and Debarment compliance requirement. Specifically, management was unable to provide written procurement policies and procedures addressing procurement transactions charged to federal awards. The entity’s procedures did not document the required procurement methods, approval requirements, documentation standards, conflict-of-interest considerations, or suspension and debarment verification procedures applicable to federally funded purchases. As a result, the entity was not in compliance with the requirement to maintain and use documented procurement procedures for procurement transactions under a federal award. Cause The condition appears to have resulted from the entity not formally updating or adopting written procurement procedures to address federal procurement requirements. While management may have followed informal purchasing practices, those practices were not formally documented, approved, or consistently communicated to personnel responsible for procurement activities under federal awards. Additionally, responsible personnel may not have been sufficiently familiar with the federal procurement documentation requirements applicable to federal awards. Effect or Potential Effect Failure to maintain documented procurement procedures increases the risk that procurement transactions charged to federal awards may not be performed in accordance with federal requirements. This could result in purchases that are not properly authorized, not adequately supported, not subject to required competition, or made with vendors that should have been excluded from participation in federal programs. The lack of documented procedures also increases the risk that suspension and debarment verification procedures may not be consistently performed or retained, which could result in federal funds being used for transactions with suspended, debarred, or otherwise excluded parties. Although no questioned costs were identified as a result of this finding, the absence of documented procurement procedures represents noncompliance with federal procurement requirements and a deficiency in internal control over compliance. Questioned Costs None noted Context The federal program was audited as a major program for the year ended June 30, 2025. During our procedures over the Procurement and Suspension and Debarment compliance requirement, we requested the entity’s written procurement policies and procedures applicable to federal awards. Management was unable to provide documented procurement procedures that addressed the required federal procurement standards. Accordingly, the entity did not demonstrate compliance with the requirement to maintain and use documented procurement procedures for federally funded procurement transactions. Repeat Finding This is not a repeat finding. Sampling Method Not applicable Recommendation We recommend management develop, formally approve, and implement written procurement policies and procedures applicable to federal awards. At a minimum, the procedures should address: • The procurement methods allowed under federal requirements. • Required documentation for procurement decisions. • Approval levels and responsibilities for federally funded purchases. • Competition and price/cost analysis requirements, when applicable. • Conflict-of-interest standards for employees involved in procurement. • Required suspension and debarment verification procedures. • Documentation retention requirements for procurement files. • Periodic review procedures to ensure procurement practices comply with federal requirements. We also recommend management provide training to employees responsible for initiating, approving, and documenting procurement transactions charged to federal awards.
Response and Views of Responsible Officials Management concurs with this finding. Management acknowledges that, during the audit period, the Organization did not maintain federally compliant written procurement procedures that addressed the requirements of Uniform Guidance for procurement transactions charged to federal awards. While the Organization generally followed purchasing and approval practices, those procedures were not formally documented and did not specifically address federal procurement standards, suspension and debarment verification, or procurement documentation requirements. Since the audit period, the Organization has substantially strengthened its procurement policies and internal controls. The Financial Policies Manual has been revised to include formal procurement procedures, purchasing approval requirements, competitive purchasing expectations, documentation standards, and financial oversight responsibilities. In addition, purchasing responsibilities have been incorporated into the Organization's strengthened internal control structure, including review by the internal bookkeeper, Executive Director, Executive Committee, and Board of Directors, as appropriate. Management also notes that strengthening procurement procedures was identified through the MIECHV monitoring process and was incorporated into the Organization's broader financial management improvements. Management believes these actions substantially improve compliance with federal procurement requirements and reduce the risks identified during the audit. Management has completed the following corrective actions: • Revised and expanded the Financial Policies Manual to include federally compliant procurement procedures and purchasing controls. • Established documented approval thresholds and purchasing authority for procurement transactions. • Implemented procurement documentation requirements, including supporting invoices, approval documentation, and retention of procurement records. • Strengthened internal review of procurement transactions through involvement of the internal bookkeeper, Executive Director, Executive Committee, and Board of Directors, as appropriate. • Incorporated procurement procedures into the Organization's broader system of internal financial controls and oversight. Management will complete the following additional actions: • Develop and implement written procedures for suspension and debarment verification for applicable federally funded purchases, including documentation of SAM.gov verification. • Develop a standardized Federal Procurement Checklist to document procurement method, approvals, required competition, suspension and debarment verification, and supporting documentation for federally funded purchases. • Establish standardized procurement files to ensure all required procurement documentation is maintained in accordance with the Organization's record retention policy. • Provide training to employees responsible for initiating, approving, or documenting procurement transactions charged to federal awards. • Conduct an annual review of procurement policies and procedures to ensure continued compliance with Uniform Guidance and federal grant requirements. Responsible Official: Josie Brittain Anticipated Completion Date: September 30, 2026
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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