Audit 297971

FY End
2023-06-30
Total Expended
$9.69M
Findings
16
Programs
18
Year: 2023 Accepted: 2024-03-26
Auditor: Cohnreznick LLP

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
384925 2023-001 Significant Deficiency - N
384926 2023-001 Significant Deficiency - N
384927 2023-001 Significant Deficiency - N
384928 2023-001 Significant Deficiency - N
384929 2023-001 Significant Deficiency - N
384930 2023-001 Significant Deficiency - N
384931 2023-001 Significant Deficiency - N
384932 2023-002 Material Weakness - L
961367 2023-001 Significant Deficiency - N
961368 2023-001 Significant Deficiency - N
961369 2023-001 Significant Deficiency - N
961370 2023-001 Significant Deficiency - N
961371 2023-001 Significant Deficiency - N
961372 2023-001 Significant Deficiency - N
961373 2023-001 Significant Deficiency - N
961374 2023-002 Material Weakness - L

Programs

ALN Program Spent Major Findings
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $1.42M Yes 1
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $971,070 Yes 0
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $925,530 Yes 1
93.696 Certified Community Behavioral Health Clinic Expansion Grants $664,276 - 0
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $639,949 - 0
93.944 Human Immunodeficiency Virus (hiv)/acquired Immunodeficiency Virus Syndrome (aids) Surveillance $520,108 - 0
93.914 Hiv Emergency Relief Project Grants $498,985 - 0
93.686 Ending the Hiv Epidemic: A Plan for America — Ryan White Hiv/aids Program Parts A and B (b) $471,494 - 0
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $334,061 - 0
93.917 Hiv Care Formula Grants $304,290 - 0
93.958 Block Grants for Community Mental Health Services $250,826 - 0
93.307 Minority Health and Health Disparities Research $161,144 - 0
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $121,176 Yes 1
93.941 Hiv Demonstration, Research, Public and Professional Education Projects $64,434 - 0
93.855 Allergy, Immunology and Transplantation Research $60,535 - 0
93.829 Section 223 Demonstration Programs to Improve Community Mental Health Services $58,493 - 0
93.242 Mental Health Research Grants $44,397 - 0
93.865 Child Health and Human Development Extramural Research $14,146 - 0

Contacts

Name Title Type
T31QQ8TJ8Q66 Patrick McGovern Auditee
2122717200 Steven D. Schwartz Auditor
No contacts on file

Notes to SEFA

Title: Basis of Presentation Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in in Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: Callen-Lorde elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. The accompanying schedule of expenditures of federal awards (the "Schedule") includes the federal award activity of Community Health Project, Inc. (d/b/a Michael Callen-Audre Lorde Community Health Center) ("Callen-Lorde") and Callen-Lorde Support, Inc. (collectively, the "Organization") under programs of the federal government for the year ended June 30, 2023. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards ("Uniform Guidance"). Because the Schedule presents only a selected portion of the operations of Callen-Lorde, it is not intended to and does not present the financial position, changes in net assets, or cash flows of the Organization.
Title: COVID-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - Assistance Listing Number 93.498 Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in in Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: Callen-Lorde elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. For the DHHS awards related to the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution ("PRF") program, DHHS has indicated the amounts on the schedule be reported corresponding to reporting requirements of the HRSA PRF Reporting Portal. Payments from DHHS for PRF are assigned to 'Payment Received Periods' (each, a Period) based upon the date each payment from the PRF was received. Each Period has a specified Period of Availability and timing of reporting requirements. Entities report into the HRSA PRF Reporting Portal after each Period's deadline to use the funds (i.e., after the end of the Period of Availability). The Schedule includes $925,530 received from DHHS between July 1, 2021 and December 31, 2021. In accordance with guidance from DHHS, this amount is presented as Period 4. Such amount was recognized as DHHS grant revenue in the consolidated financial statements for the year ended June 30, 2022.
Title: Teaching Health Center Graduate Medical Education Payment program Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in in Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: Callen-Lorde elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. The Center expended $180,950 of the teaching Health Center Graduate Medical Education Payment program funding it received from the U.S Department of Health and Human Services. The said program is funded under Federal Assistance Listing Number 93.530 which is excluded from coverage under 2 CFR 200, Subpart F – Audit Requirements. Thus, it is not included in the accompanying Schedule.

Finding Details

Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-002 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 - Reporting (Material Weakness) Criteria: The Coronavirus Aid, Relief, and Economic Security ("CARES") Act and American Rescue Plan ("ARP") Act of 2021 appropriated funds to reimburse eligible healthcare providers for health care related expenses or lost revenues attributable to COVID-19. These funds were distributed by Health Resources and Services Administration ("HRSA"). HRSA developed the Provider Relief Fund ("PRF") Reporting Portal to enable PRF and ARP Rural recipients to comply with mandatory reporting requirements. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the Organization's submission to the PRF Portal included inconsistencies with the underlying supporting accounting records. Cause: Due to the timing of the completion of the audit and the portal report submission deadline, certain audit-related adjustments were not included in the report submitted to the PRF portal. Effect: The Organization's report in the PRF portal does not agree to the underlying supporting accounting records. Questioned costs: None Context: Although there were inconsistencies between the actual revenue amounts reported in the PRF portal and the underlying supporting accounting records, the Organization had an adequate amount of lost revenue to earn the PRF funding received. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Management response: Management is in agreement with the audit finding that the PRF portal submission was not consistent with the underlying supporting accounting records. Measures will be taken to implement controls that will ensure that reports are reviewed and agreed to supporting underlying accounting records before they are submitted.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.
Item 2023-002 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing Number 93.498 - Reporting (Material Weakness) Criteria: The Coronavirus Aid, Relief, and Economic Security ("CARES") Act and American Rescue Plan ("ARP") Act of 2021 appropriated funds to reimburse eligible healthcare providers for health care related expenses or lost revenues attributable to COVID-19. These funds were distributed by Health Resources and Services Administration ("HRSA"). HRSA developed the Provider Relief Fund ("PRF") Reporting Portal to enable PRF and ARP Rural recipients to comply with mandatory reporting requirements. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the Organization's submission to the PRF Portal included inconsistencies with the underlying supporting accounting records. Cause: Due to the timing of the completion of the audit and the portal report submission deadline, certain audit-related adjustments were not included in the report submitted to the PRF portal. Effect: The Organization's report in the PRF portal does not agree to the underlying supporting accounting records. Questioned costs: None Context: Although there were inconsistencies between the actual revenue amounts reported in the PRF portal and the underlying supporting accounting records, the Organization had an adequate amount of lost revenue to earn the PRF funding received. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that the Organization strengthen its system of internal controls to ensure that all reporting that is done and submitted is consistent with requirements and instructions as provided by regulatory agencies. Management response: Management is in agreement with the audit finding that the PRF portal submission was not consistent with the underlying supporting accounting records. Measures will be taken to implement controls that will ensure that reports are reviewed and agreed to supporting underlying accounting records before they are submitted.