Audit 301708

FY End
2023-06-30
Total Expended
$3.95M
Findings
6
Programs
4
Organization: Operation Samahan, Inc. (CA)
Year: 2023 Accepted: 2024-04-01

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
391102 2023-002 Material Weakness Yes N
391103 2023-002 Material Weakness Yes N
391104 2023-002 Material Weakness Yes N
967544 2023-002 Material Weakness Yes N
967545 2023-002 Material Weakness Yes N
967546 2023-002 Material Weakness Yes N

Contacts

Name Title Type
DYCWD2XGWRV1 Liz David Auditee
8442002426 Shaun Johnson 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 the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. The Organization has not elected to use the 10 percent de minimis indirect cost rate as allowed under the Uniform Guidance. De Minimis Rate Used: N Rate Explanation: The Organization has not elected 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 Operation Samahan, Inc. doing business as OPSAM Health (the Organization) under programs of the federal government for the year ended June 30, 2023. Amounts reported on the Schedule for Assistance Listing Number 93.498 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions are based upon the December 31, 2022, Provider Relief Fund report. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. CFR 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 the Organization, it is not intended to and does not present the financial position, changes in net assets, or cash flows of the Organization.

Finding Details

2023-002 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, H8GCS48510, C14CS39779 Criteria OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patients ability to pay.” [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient’s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 15 who did not have the correct sliding fee applied. In addition, 3 of the 15 misapplied sliding fees were due to lack of application on file or incomplete application and 8 of the 15 misapplied sliding fees were due to the sliding fees scales not being correctly calculated by the billing software after changes to the scale were made. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. In addition, the billing software was not properly updated for changes in the sliding fee scale to apply the sliding fees correctly based on the levels supported by the patient applications. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. In addition, we recommend that after sliding fee scales are updated sufficient testing of billing software is performed to ensure that sliding fees scales are being properly applied. Views of responsible officials and planned corrective action Management …
2023-002 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, H8GCS48510, C14CS39779 Criteria OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patients ability to pay.” [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient’s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 15 who did not have the correct sliding fee applied. In addition, 3 of the 15 misapplied sliding fees were due to lack of application on file or incomplete application and 8 of the 15 misapplied sliding fees were due to the sliding fees scales not being correctly calculated by the billing software after changes to the scale were made. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. In addition, the billing software was not properly updated for changes in the sliding fee scale to apply the sliding fees correctly based on the levels supported by the patient applications. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. In addition, we recommend that after sliding fee scales are updated sufficient testing of billing software is performed to ensure that sliding fees scales are being properly applied. Views of responsible officials and planned corrective action Management …
2023-002 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, H8GCS48510, C14CS39779 Criteria OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patients ability to pay.” [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient’s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 15 who did not have the correct sliding fee applied. In addition, 3 of the 15 misapplied sliding fees were due to lack of application on file or incomplete application and 8 of the 15 misapplied sliding fees were due to the sliding fees scales not being correctly calculated by the billing software after changes to the scale were made. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. In addition, the billing software was not properly updated for changes in the sliding fee scale to apply the sliding fees correctly based on the levels supported by the patient applications. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. In addition, we recommend that after sliding fee scales are updated sufficient testing of billing software is performed to ensure that sliding fees scales are being properly applied. Views of responsible officials and planned corrective action Management …
2023-002 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, H8GCS48510, C14CS39779 Criteria OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patients ability to pay.” [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient’s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 15 who did not have the correct sliding fee applied. In addition, 3 of the 15 misapplied sliding fees were due to lack of application on file or incomplete application and 8 of the 15 misapplied sliding fees were due to the sliding fees scales not being correctly calculated by the billing software after changes to the scale were made. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. In addition, the billing software was not properly updated for changes in the sliding fee scale to apply the sliding fees correctly based on the levels supported by the patient applications. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. In addition, we recommend that after sliding fee scales are updated sufficient testing of billing software is performed to ensure that sliding fees scales are being properly applied. Views of responsible officials and planned corrective action Management …
2023-002 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, H8GCS48510, C14CS39779 Criteria OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patients ability to pay.” [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient’s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 15 who did not have the correct sliding fee applied. In addition, 3 of the 15 misapplied sliding fees were due to lack of application on file or incomplete application and 8 of the 15 misapplied sliding fees were due to the sliding fees scales not being correctly calculated by the billing software after changes to the scale were made. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. In addition, the billing software was not properly updated for changes in the sliding fee scale to apply the sliding fees correctly based on the levels supported by the patient applications. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. In addition, we recommend that after sliding fee scales are updated sufficient testing of billing software is performed to ensure that sliding fees scales are being properly applied. Views of responsible officials and planned corrective action Management …
2023-002 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, H8GCS48510, C14CS39779 Criteria OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patients ability to pay.” [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient’s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 15 who did not have the correct sliding fee applied. In addition, 3 of the 15 misapplied sliding fees were due to lack of application on file or incomplete application and 8 of the 15 misapplied sliding fees were due to the sliding fees scales not being correctly calculated by the billing software after changes to the scale were made. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. In addition, the billing software was not properly updated for changes in the sliding fee scale to apply the sliding fees correctly based on the levels supported by the patient applications. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. In addition, we recommend that after sliding fee scales are updated sufficient testing of billing software is performed to ensure that sliding fees scales are being properly applied. Views of responsible officials and planned corrective action Management …