Grant County Public Hospital District No. 5Local Government

The District did not have adequate internal controls to ensure compliance with federal procurement requirements. Description of Condition The purpose of the Health Center Program is to improve the health of underserved communities and vulnerable populations in the United States by ensuring continued access to comprehensive, culturally competent and quality primary health care services. The District spent $1,468,524 through this program to provide primary and preventive health care services to underserved communities. Federal regulations require recipients to establish and follow internal controls that ensure compliance with program requirements. These controls include understanding program requirements and monitoring the effectiveness of established controls. Federal regulations also require recipients to follow their own documented procurement procedures, which must conform to the Uniform Guidance procurement standards found in 2 CFR 200.318-327. The procedures must reflect the most restrictive of applicable federal requirements, state laws or local policies. When using federal funds to purchase goods or services, governments must apply the most restrictive of federal requirements, state law or local policies by obtaining quotes or following a competitive bidding process, depending on the estimated cost of the purchase or project. The District’s adopted policy includes procedures for the purchase of supplies, materials, equipment and services. However, the thresholds do not conform to the most restrictive of $75,000 for public works contracts, and the policy does not include required elements to conform with Uniform Guidance requirements. In addition, the District entered into two contracts for public work projects during the audit period. One contract was for the installation of a modular building for $745,172, and the other was for a clinic renovation for $247,250. Both projects were partially paid with federal funds, and they required competitive bidding. Our audit found the District did not follow proper procurement procedures for these projects to ensure compliance with Uniform Guidance requirements. We consider these deficiencies in internal controls to be a material weakness. Cause of Condition District employees did not know about the policy requirements. Additionally, District officials said that obtaining quotes for these projects was the most economical process because the District has previously experienced difficulties with obtaining contractors within its remote location. Effect of Condition Without written procedures in place, the District is at greater risk of noncompliance with the most restrictive of federal, state, or local procurement methods when procuring contractors paid all or in part with federal funds. Since the District did not comply with federal procurement requirements to formally bid two public work projects, it cannot demonstrate it received the best price for the services provided. Recommendation We recommend the District ensure its written procurement procedures comply with the most restrictive of federal, state or local requirements, as required by Uniform Guidance. We also recommend the District strengthen its internal controls over procuring public work projects to ensure compliance with federal procurement requirements. District’s Response During the planning phase of each project, the District, working closely with its architectural firm, conducted extensive research on available contractors within the region with specific experience in construction for health care practice. It was determined that while there are an adequate number of contractors in the area; there is a robust housing construction trend occurring at present. As a result, contractors with specific experience health care construction conveyed they were not interested in the size of the District project to consider submitting a bid. The project then became a single source with only one vendor interested in submitting a bid for the work proposed. It was not feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade press to solicit bids to maximize competition. The procurement for the prefabricated modular building was a unique circumstance where there are a limited number of vendors that can supply the product needed by the District within a reasonable geographic vicinity. The product needed by the District within a reasonable geographic vicinity. The District obtained written proposals from three known supplies of the specialty item for procurement. The request included specifications that defines the item of service needed that allowed for the vendor to properly respond. A cost and price analysis was conducted based on the response from the bids solicited. The final award was based on price as well as the lack of competition due to limited specialty suppliers. For this project, competition was determined inadequate due to the limited number of specialty vendors with the ability to fulfill the District requirements of a prefabricated structure. Therefore, it was not deemed feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade presses. Auditor’s Remarks We thank the District for its cooperation and assistance during the audit and will review the status of this issue during the next audit. Applicable Laws and Regulations Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), section 516, Audit findings, establishes reporting requirements for audit findings. Title 2 CFR Part 200, Uniform Guidance, section 303, Internal controls, describes the requirements for auditees to maintain internal controls over federal programs and comply with federal program requirements. The American Institute of Certified Public Accountants defines significant deficiencies and material weaknesses in its Codification of Statements on Auditing Standards, section 935, Compliance Audits, paragraph 11. Title 2 CFR Part 200, Uniform Guidance, section 318, describes general procurement standard requirements for auditees to follow. All procurement transactions for the acquisition of property or services required under a federal award must be conducted in a manner providing full and open competition consistent with the standards of this section.

The District did not have adequate internal controls to ensure compliance with federal procurement requirements. Assistance Listing Number and Title: 93.224 – Health Center Program 93.527 – Grants for New and Expanded Services under the Health Center Program Federal Grantor Name: U.S. Department of Health and Human Services Federal Award/Contract Number: N/A Pass-through Entity Name: N/A Pass-through Award/Contract Number: N/A Known Questioned Cost Amount: $0 Prior Year Audit Finding: No Description of Condition The purpose of the Health Center Program is to improve the health of underserved communities and vulnerable populations in the United States by ensuring continued access to comprehensive, culturally competent and quality primary health care services. The District spent $1,468,524 through this program to provide primary and preventive health care services to underserved communities. Federal regulations require recipients to establish and follow internal controls that ensure compliance with program requirements. These controls include understanding program requirements and monitoring the effectiveness of established controls. Federal regulations also require recipients to follow their own documented procurement procedures, which must conform to the Uniform Guidance procurement standards found in 2 CFR 200.318-327. The procedures must reflect the most restrictive of applicable federal requirements, state laws or local policies. When using federal funds to purchase goods or services, governments must apply the most restrictive of federal requirements, state law or local policies by obtaining quotes or following a competitive bidding process, depending on the estimated cost of the purchase or project. The District’s adopted policy includes procedures for the purchase of supplies, materials, equipment and services. However, the thresholds do not conform to the most restrictive of $75,000 for public works contracts, and the policy does not include required elements to conform with Uniform Guidance requirements. In addition, the District entered into two contracts for public work projects during the audit period. One contract was for the installation of a modular building for $745,172, and the other was for a clinic renovation for $247,250. Both projects were partially paid with federal funds, and they required competitive bidding. Our audit found the District did not follow proper procurement procedures for these projects to ensure compliance with Uniform Guidance requirements. We consider these deficiencies in internal controls to be a material weakness. Cause of Condition District employees did not know about the policy requirements. Additionally, District officials said that obtaining quotes for these projects was the most economical process because the District has previously experienced difficulties with obtaining contractors within its remote location. Effect of Condition Without written procedures in place, the District is at greater risk of noncompliance with the most restrictive of federal, state, or local procurement methods when procuring contractors paid all or in part with federal funds. Since the District did not comply with federal procurement requirements to formally bid two public work projects, it cannot demonstrate it received the best price for the services provided. Recommendation We recommend the District ensure its written procurement procedures comply with the most restrictive of federal, state or local requirements, as required by Uniform Guidance. We also recommend the District strengthen its internal controls over procuring public work projects to ensure compliance with federal procurement requirements. District’s Response During the planning phase of each project, the District, working closely with its architectural firm, conducted extensive research on available contractors within the region with specific experience in construction for health care practice. It was determined that while there are an adequate number of contractors in the area; there is a robust housing construction trend occurring at present. As a result, contractors with specific experience health care construction conveyed they were not interested in the size of the District project to consider submitting a bid. The project then became a single source with only one vendor interested in submitting a bid for the work proposed. It was not feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade press to solicit bids to maximize competition. The procurement for the pre-fabricated modular building was a unique circumstance where there are a limited number of vendors that can supply the product needed by the District within a reasonable geographic vicinity. The product needed by the District within a reasonable geographic vicinity. The District obtained written proposals from three known supplies of the specialty item for procurement. The request included specifications that defines the item of service needed that allowed for the vendor to properly respond. A cost and price analysis was conducted based on the response from the bids solicited. The final award was based on price as well as the lack of competition due to limited specialty suppliers. For this project, competition was determined inadequate due to the limited number of specialty vendors with the ability to fulfill the District requirements of a pre- fabricated structure. Therefore, it was not deemed feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade presses. Auditor’s Remarks We thank the District for its cooperation and assistance during the audit and will review the status of this issue during the next audit. Applicable Laws and Regulations Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), section 516, Audit findings, establishes reporting requirements for audit findings. Title 2 CFR Part 200, Uniform Guidance, section 303, Internal controls, describes the requirements for auditees to maintain internal controls over federal programs and comply with federal program requirements. The American Institute of Certified Public Accountants defines significant deficiencies and material weaknesses in its Codification of Statements on Auditing Standards, section 935, Compliance Audits, paragraph 11. Title 2 CFR Part 200, Uniform Guidance, section 318, describes general procurement standard requirements for auditees to follow. All procurement transactions for the acquisition of property or services required under a federal award must be conducted in a manner providing full and open competition consistent with the standards of this section.

The District did not have adequate internal controls to ensure compliance with federal procurement requirements. Description of Condition The purpose of the Health Center Program is to improve the health of underserved communities and vulnerable populations in the United States by ensuring continued access to comprehensive, culturally competent and quality primary health care services. The District spent $1,468,524 through this program to provide primary and preventive health care services to underserved communities. Federal regulations require recipients to establish and follow internal controls that ensure compliance with program requirements. These controls include understanding program requirements and monitoring the effectiveness of established controls. Federal regulations also require recipients to follow their own documented procurement procedures, which must conform to the Uniform Guidance procurement standards found in 2 CFR 200.318-327. The procedures must reflect the most restrictive of applicable federal requirements, state laws or local policies. When using federal funds to purchase goods or services, governments must apply the most restrictive of federal requirements, state law or local policies by obtaining quotes or following a competitive bidding process, depending on the estimated cost of the purchase or project. The District’s adopted policy includes procedures for the purchase of supplies, materials, equipment and services. However, the thresholds do not conform to the most restrictive of $75,000 for public works contracts, and the policy does not include required elements to conform with Uniform Guidance requirements. In addition, the District entered into two contracts for public work projects during the audit period. One contract was for the installation of a modular building for $745,172, and the other was for a clinic renovation for $247,250. Both projects were partially paid with federal funds, and they required competitive bidding. Our audit found the District did not follow proper procurement procedures for these projects to ensure compliance with Uniform Guidance requirements. We consider these deficiencies in internal controls to be a material weakness. Cause of Condition District employees did not know about the policy requirements. Additionally, District officials said that obtaining quotes for these projects was the most economical process because the District has previously experienced difficulties with obtaining contractors within its remote location. Effect of Condition Without written procedures in place, the District is at greater risk of noncompliance with the most restrictive of federal, state, or local procurement methods when procuring contractors paid all or in part with federal funds. Since the District did not comply with federal procurement requirements to formally bid two public work projects, it cannot demonstrate it received the best price for the services provided. Recommendation We recommend the District ensure its written procurement procedures comply with the most restrictive of federal, state or local requirements, as required by Uniform Guidance. We also recommend the District strengthen its internal controls over procuring public work projects to ensure compliance with federal procurement requirements. District’s Response During the planning phase of each project, the District, working closely with its architectural firm, conducted extensive research on available contractors within the region with specific experience in construction for health care practice. It was determined that while there are an adequate number of contractors in the area; there is a robust housing construction trend occurring at present. As a result, contractors with specific experience health care construction conveyed they were not interested in the size of the District project to consider submitting a bid. The project then became a single source with only one vendor interested in submitting a bid for the work proposed. It was not feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade press to solicit bids to maximize competition. The procurement for the prefabricated modular building was a unique circumstance where there are a limited number of vendors that can supply the product needed by the District within a reasonable geographic vicinity. The product needed by the District within a reasonable geographic vicinity. The District obtained written proposals from three known supplies of the specialty item for procurement. The request included specifications that defines the item of service needed that allowed for the vendor to properly respond. A cost and price analysis was conducted based on the response from the bids solicited. The final award was based on price as well as the lack of competition due to limited specialty suppliers. For this project, competition was determined inadequate due to the limited number of specialty vendors with the ability to fulfill the District requirements of a prefabricated structure. Therefore, it was not deemed feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade presses. Auditor’s Remarks We thank the District for its cooperation and assistance during the audit and will review the status of this issue during the next audit. Applicable Laws and Regulations Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), section 516, Audit findings, establishes reporting requirements for audit findings. Title 2 CFR Part 200, Uniform Guidance, section 303, Internal controls, describes the requirements for auditees to maintain internal controls over federal programs and comply with federal program requirements. The American Institute of Certified Public Accountants defines significant deficiencies and material weaknesses in its Codification of Statements on Auditing Standards, section 935, Compliance Audits, paragraph 11. Title 2 CFR Part 200, Uniform Guidance, section 318, describes general procurement standard requirements for auditees to follow. All procurement transactions for the acquisition of property or services required under a federal award must be conducted in a manner providing full and open competition consistent with the standards of this section.

The District did not have adequate internal controls to ensure compliance with federal procurement requirements. Assistance Listing Number and Title: 93.224 – Health Center Program 93.527 – Grants for New and Expanded Services under the Health Center Program Federal Grantor Name: U.S. Department of Health and Human Services Federal Award/Contract Number: N/A Pass-through Entity Name: N/A Pass-through Award/Contract Number: N/A Known Questioned Cost Amount: $0 Prior Year Audit Finding: No Description of Condition The purpose of the Health Center Program is to improve the health of underserved communities and vulnerable populations in the United States by ensuring continued access to comprehensive, culturally competent and quality primary health care services. The District spent $1,468,524 through this program to provide primary and preventive health care services to underserved communities. Federal regulations require recipients to establish and follow internal controls that ensure compliance with program requirements. These controls include understanding program requirements and monitoring the effectiveness of established controls. Federal regulations also require recipients to follow their own documented procurement procedures, which must conform to the Uniform Guidance procurement standards found in 2 CFR 200.318-327. The procedures must reflect the most restrictive of applicable federal requirements, state laws or local policies. When using federal funds to purchase goods or services, governments must apply the most restrictive of federal requirements, state law or local policies by obtaining quotes or following a competitive bidding process, depending on the estimated cost of the purchase or project. The District’s adopted policy includes procedures for the purchase of supplies, materials, equipment and services. However, the thresholds do not conform to the most restrictive of $75,000 for public works contracts, and the policy does not include required elements to conform with Uniform Guidance requirements. In addition, the District entered into two contracts for public work projects during the audit period. One contract was for the installation of a modular building for $745,172, and the other was for a clinic renovation for $247,250. Both projects were partially paid with federal funds, and they required competitive bidding. Our audit found the District did not follow proper procurement procedures for these projects to ensure compliance with Uniform Guidance requirements. We consider these deficiencies in internal controls to be a material weakness. Cause of Condition District employees did not know about the policy requirements. Additionally, District officials said that obtaining quotes for these projects was the most economical process because the District has previously experienced difficulties with obtaining contractors within its remote location. Effect of Condition Without written procedures in place, the District is at greater risk of noncompliance with the most restrictive of federal, state, or local procurement methods when procuring contractors paid all or in part with federal funds. Since the District did not comply with federal procurement requirements to formally bid two public work projects, it cannot demonstrate it received the best price for the services provided. Recommendation We recommend the District ensure its written procurement procedures comply with the most restrictive of federal, state or local requirements, as required by Uniform Guidance. We also recommend the District strengthen its internal controls over procuring public work projects to ensure compliance with federal procurement requirements. District’s Response During the planning phase of each project, the District, working closely with its architectural firm, conducted extensive research on available contractors within the region with specific experience in construction for health care practice. It was determined that while there are an adequate number of contractors in the area; there is a robust housing construction trend occurring at present. As a result, contractors with specific experience health care construction conveyed they were not interested in the size of the District project to consider submitting a bid. The project then became a single source with only one vendor interested in submitting a bid for the work proposed. It was not feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade press to solicit bids to maximize competition. The procurement for the pre-fabricated modular building was a unique circumstance where there are a limited number of vendors that can supply the product needed by the District within a reasonable geographic vicinity. The product needed by the District within a reasonable geographic vicinity. The District obtained written proposals from three known supplies of the specialty item for procurement. The request included specifications that defines the item of service needed that allowed for the vendor to properly respond. A cost and price analysis was conducted based on the response from the bids solicited. The final award was based on price as well as the lack of competition due to limited specialty suppliers. For this project, competition was determined inadequate due to the limited number of specialty vendors with the ability to fulfill the District requirements of a pre- fabricated structure. Therefore, it was not deemed feasible or economical to publicize the solicitation through appropriate periodicals of general circulation and trade presses. Auditor’s Remarks We thank the District for its cooperation and assistance during the audit and will review the status of this issue during the next audit. Applicable Laws and Regulations Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), section 516, Audit findings, establishes reporting requirements for audit findings. Title 2 CFR Part 200, Uniform Guidance, section 303, Internal controls, describes the requirements for auditees to maintain internal controls over federal programs and comply with federal program requirements. The American Institute of Certified Public Accountants defines significant deficiencies and material weaknesses in its Codification of Statements on Auditing Standards, section 935, Compliance Audits, paragraph 11. Title 2 CFR Part 200, Uniform Guidance, section 318, describes general procurement standard requirements for auditees to follow. All procurement transactions for the acquisition of property or services required under a federal award must be conducted in a manner providing full and open competition consistent with the standards of this section.

2019-001 The District did not have adequate internal controls to ensure compliance with federal suspension and debarment requirements. CFDA Number and Title: 93.527 Grants for New and Expanded Services under the Health Center Program Federal Grantor Name: U.S. Department of Health and Human Services Federal Award/Contract Number: N/A Pass-through Entity Name: N/A Pass-through Award/Contract Number: N/A Questioned Cost Amount: $0 Description of Condition The purpose of the Health Center Program (HCP) is to improve the health of the Nation?s underserved communities and vulnerable populations by ensuring continued access to comprehensive, culturally competent, quality primary health care services. The District spent $1,017,357 through this program to provide primary and preventive health care services to the underserved. Federal requirements prohibit grant recipients from contracting with parties suspended or debarred from doing business with the federal government. Whenever the District contracts for goods and services that it expects to equal or exceed $25,000, paid all or in part with federal funds, it must verify the contractors have not been suspended or debarred or otherwise excluded. This verification may be accomplished by (1) collecting a written certification from the contractor, (2) adding a clause or condition into the contract where the contractor states it is not suspended and debarred, or (3) checking the federal Excluded Parties List System (EPLS) maintained by the U.S. General Service Administration. The District must meet one of these requirements before awarding the contract and must maintain documentation to demonstrate compliance. The District had internal controls in place to verify the suspension and debarment status for purchase contracts exceeding $25,000. However, the District did not have a process in place to check the suspension and debarment status for service contracts exceeding $25,000. We consider this deficiency in internal controls to be a material weakness. The issue was not reported as a finding in the prior audit. Cause of Condition The District incorrectly relied on the National Practitioner Data Base (NPDB) verification of medical licenses and credentials for practitioners to satisfy the suspension and debarment requirements. Effect of Condition The District did not obtain a written certification, insert a clause into a contract or review EPLS before entering into the contract or agreement to verify one of two contractors tested were not suspended and debarred from participating in federal programs. The City paid this service contractor $57,697 during fiscal year 2019. Without adequate internal controls over suspension and debarment requirements, the District cannot guarantee it pays federal funds only to eligible contractors. Any payments made to an ineligible party would be subject to recovery by the funding agency. We subsequently verified the contractor was not suspended or debarred. Therefore, we are not questioning costs. Recommendation We recommend the District strengthen internal controls over service provider agreements charged to federal programs to verify before entering into contracts, that all contractors it expects to pay $25,000 or more of federal funds during the year are not suspended or debarred from participating in federal programs. District?s Response The District acknowledges the error in not querying the System for Award Management data base to obtain assurance its service contractors are not excluded or debarred from participating in a Federal program as required by its grant terms and conditions prior to executing a contract. The oversight was immediately remedied and a process implemented for continued compliance through the use of dedicated staff (administrative assistant) to complete the query at the time of contracting as well as periodically checking the list to ensure changes in the contractor status is known immediately. Auditor?s Remarks We thank the District for its cooperation and assistance during the audit and acknowledge its commitment to improving the condition described. We will review the status of this issue during our next audit. Applicable Laws and Regulations The American Institute of Certified Public Accountants defines significant deficiencies and material weaknesses in its Codification of Statements on Auditing Standards, section 935, Compliance Audits, paragraph 11. Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), section 516, Audit findings, establishes reporting requirements for audit findings. Title 2 CFR Part 200, Uniform Guidance, section 303 Internal controls, establishes requirements for management of Federal awards to non-Federal entities. Title 2 CFR Part 180, OMB Guidelines to Agencies on Government wide Department and Suspension (Nonprocurement) establishes non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689.