Audit 302373

FY End
2023-01-31
Total Expended
$2.06M
Findings
4
Programs
5
Year: 2023 Accepted: 2024-04-02
Auditor: Dza PLLC

Organization Exclusion Status:

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Contacts

Name Title Type
HF3GBSNCFSM5 Kendra Newbold Auditee
5413472529 Shaun Johnson Auditor
No contacts on file

Notes to SEFA

Title: Basis of Presentation Accounting Policies: Expenditures reported on this 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 allowed under the Uniform Guidance. De Minimis Rate Used: N Rate Explanation: The entity did not utilize the de minimis cost rate. The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal award activity of the Organization under programs of the federal government for the year ended January 31, 2023. The information in the Schedule is presented in accordance with the requirements of 2 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 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

2023-001 Special Tests and Provisions - Sliding Fee Discounts Program Information Federal Agency U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26602, H8FCS40619, H8DCS35705, H8GCS47935, H8ECS44806 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 audit we noted inadequate records to support the calculation of sliding fee discounts applied for 10 out of 25 patient encounters. Context Certain records were not retained when the Organization converted to its new electronic health records (EHR) system. Patient reports from the prior EHR system were not available to provide the appropriate transaction-level detail. Cause Records were not retained sufficient to calculate the sliding fee discount applied. Effect Improper sliding fee discount could have been applied to a patient’s account. Questioned Costs None identified. Recommendation We recommend reporting capabilities be retained in the legacy system’s EHR or transferred to the new system’s EHR when system upgrades occur. Views of responsible officials and planned corrective action During the conversion to the new EMR, patient medical record history and other documents were transferred to the new EMR, which included the sliding fee scale (SFS) applications. However, Management was unable to access the former EMR, eClinical Works (eCW), or download the details of the financial transactions showing the SFS discount was applied to the claim after the contract with eCW was terminated. Upon termination, eCW only offered reports of the financial transaction data, which Management provided to the auditors; however, this was not sufficient for demonstrating the discount on the claim as Management could not show the claim in eCW. Management will create a procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. This procedure will be created by March 31, 2024.
2023-001 Special Tests and Provisions - Sliding Fee Discounts Program Information Federal Agency U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26602, H8FCS40619, H8DCS35705, H8GCS47935, H8ECS44806 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 audit we noted inadequate records to support the calculation of sliding fee discounts applied for 10 out of 25 patient encounters. Context Certain records were not retained when the Organization converted to its new electronic health records (EHR) system. Patient reports from the prior EHR system were not available to provide the appropriate transaction-level detail. Cause Records were not retained sufficient to calculate the sliding fee discount applied. Effect Improper sliding fee discount could have been applied to a patient’s account. Questioned Costs None identified. Recommendation We recommend reporting capabilities be retained in the legacy system’s EHR or transferred to the new system’s EHR when system upgrades occur. Views of responsible officials and planned corrective action During the conversion to the new EMR, patient medical record history and other documents were transferred to the new EMR, which included the sliding fee scale (SFS) applications. However, Management was unable to access the former EMR, eClinical Works (eCW), or download the details of the financial transactions showing the SFS discount was applied to the claim after the contract with eCW was terminated. Upon termination, eCW only offered reports of the financial transaction data, which Management provided to the auditors; however, this was not sufficient for demonstrating the discount on the claim as Management could not show the claim in eCW. Management will create a procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. This procedure will be created by March 31, 2024.
2023-001 Special Tests and Provisions - Sliding Fee Discounts Program Information Federal Agency U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26602, H8FCS40619, H8DCS35705, H8GCS47935, H8ECS44806 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 audit we noted inadequate records to support the calculation of sliding fee discounts applied for 10 out of 25 patient encounters. Context Certain records were not retained when the Organization converted to its new electronic health records (EHR) system. Patient reports from the prior EHR system were not available to provide the appropriate transaction-level detail. Cause Records were not retained sufficient to calculate the sliding fee discount applied. Effect Improper sliding fee discount could have been applied to a patient’s account. Questioned Costs None identified. Recommendation We recommend reporting capabilities be retained in the legacy system’s EHR or transferred to the new system’s EHR when system upgrades occur. Views of responsible officials and planned corrective action During the conversion to the new EMR, patient medical record history and other documents were transferred to the new EMR, which included the sliding fee scale (SFS) applications. However, Management was unable to access the former EMR, eClinical Works (eCW), or download the details of the financial transactions showing the SFS discount was applied to the claim after the contract with eCW was terminated. Upon termination, eCW only offered reports of the financial transaction data, which Management provided to the auditors; however, this was not sufficient for demonstrating the discount on the claim as Management could not show the claim in eCW. Management will create a procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. This procedure will be created by March 31, 2024.
2023-001 Special Tests and Provisions - Sliding Fee Discounts Program Information Federal Agency U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26602, H8FCS40619, H8DCS35705, H8GCS47935, H8ECS44806 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 audit we noted inadequate records to support the calculation of sliding fee discounts applied for 10 out of 25 patient encounters. Context Certain records were not retained when the Organization converted to its new electronic health records (EHR) system. Patient reports from the prior EHR system were not available to provide the appropriate transaction-level detail. Cause Records were not retained sufficient to calculate the sliding fee discount applied. Effect Improper sliding fee discount could have been applied to a patient’s account. Questioned Costs None identified. Recommendation We recommend reporting capabilities be retained in the legacy system’s EHR or transferred to the new system’s EHR when system upgrades occur. Views of responsible officials and planned corrective action During the conversion to the new EMR, patient medical record history and other documents were transferred to the new EMR, which included the sliding fee scale (SFS) applications. However, Management was unable to access the former EMR, eClinical Works (eCW), or download the details of the financial transactions showing the SFS discount was applied to the claim after the contract with eCW was terminated. Upon termination, eCW only offered reports of the financial transaction data, which Management provided to the auditors; however, this was not sufficient for demonstrating the discount on the claim as Management could not show the claim in eCW. Management will create a procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. This procedure will be created by March 31, 2024.