Audit 304417

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation for Expenses Submitted for Reimbursement (initially reported 2021) Assistance Listing Number: 93.224 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $335,534 Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to allowable costs management should review submission of reimbursement request to ensure costs submitted can be supported by underlying accounting documentation. Cause: Management did not review prior to submission of costs for reimbursement to ensure they could be supported by underlying accounting documentation and had not been applied as direct costs of another federal program. Effect: Submission of unallowable costs under the program may result in losing funding under the program. Recommendation: Management should review all costs prior to request for reimbursement for determination that costs could be supported by underlying accounting documentation and that costs were not included as a cost of any other federally financed program in either the current or prior period. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Controls Related to Filing Reports (initially reported 2021) Assistance Listing Number: 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: COVID-19 Provider Relief Fund Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: The Organization did not have a process in place for review of the data being reported on the HRSA website for the funds being expensed under the Provider Relief Fund program. Effect: The Organization could submit incorrect information. Recommendation: The documentation should be kept that clearly documents who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its reporting policy and implemented the changes. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation for Expenses Submitted for Reimbursement (initially reported 2021) Assistance Listing Number: 93.224 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Compliance Requirement: Allowable Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $335,534 Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to allowable costs management should review submission of reimbursement request to ensure costs submitted can be supported by underlying accounting documentation. Cause: Management did not review prior to submission of costs for reimbursement to ensure they could be supported by underlying accounting documentation and had not been applied as direct costs of another federal program. Effect: Submission of unallowable costs under the program may result in losing funding under the program. Recommendation: Management should review all costs prior to request for reimbursement for determination that costs could be supported by underlying accounting documentation and that costs were not included as a cost of any other federally financed program in either the current or prior period. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Internal Controls over the Application of the Sliding Fee Scale (prior two years 2020-101 and 2019-103) (initially reported 2014) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. - Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. - Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. - Six of the thirty-two encounters sampled where the sliding scale was used had the wrong sliding fee scale applied based on information obtained about the patient’s family size and income. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. 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 based on the patient's ability to pay ( 42 U.S.C 254b(k)(3)(G)(i)). The patient's ability to pay is based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (42 U.S.C 9902(2)). Cause: Failure to apply the sliding fee correctly, as noted in six of the encounters above, was due to improper staff training or failure to properly monitor the process. Failure to apply the sliding fee scales due to the requirements of the agreement with the local school district and procedures applied to the disaster recovery bus program do not follow the written procedures of the Organization for use of the sliding fee scale. Effect: The Organization could be incorrectly billing for services and maintaining customer account balances at incorrect amounts. Recommendation: Staff should be consistently trained in how patients should complete the intake forms, including the sliding fee scale application, and require patients complete the form appropriately, including refusal to provide information, if applicable. Staff should also be consistently trained on what documentation is considered sufficient to support income identified as well as verify the application is consistent with the documentation and, when needed, clearly document the reasons for inconsistency. Staff should make every effort to obtain documentation of patient income in accordance with internal policies and procedures. Patients should be billed the usual and customer billing rates for all services until all documentation is received or policies are adjusted to allow for self-determination by patients in certain situations. A process should be put in place to track patients in order to attempt further collection of the necessary data that would allow for adjustment of the bill after the fact when necessary. These exceptions should be tracked each month with the monthly review by the regional operations managers. The reviews by the regional operations managers should be documented and retained including the results and corrective action of the follow-up on deficiencies noted. The Organization should discuss with HRSA what could be done to either adjust policies and procedures used during the school visits to be compliant or obtain a waiver from HRSA to indicate their knowledge and approval of the school visits and disaster bus program visits not being compliant with the application of the sliding fee scale requirements. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion.

Lack of Cash Management Documentation (prior two years 2020-102 and 2019-104) (initially reported 2016) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Cash Management Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324-01 (2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenditures and therefore could not be agreed to the actual approved wages paid prior to the reimbursement request. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Based on grant compliance requirements related to cash management for grants and cooperative agreements to nonfederal entities that are paid on a reimbursement basis, supporting documentation should include the actual costs for which reimbursement was requested and were paid prior to the date of the reimbursement request. Cause: Reimbursement was requested based on the budgeted payroll expenses made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. No indication of a review process involved beyond the CFO preparing a calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation and were paid prior to the reimbursement request. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be based on actual and not budgeted payroll and it should be prepared and reviewed by someone other than the preparer. Also, it should directly link the amount requested to the related expenses to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenses are being considered expended through these funds, and that funds were requested and applied to the correct period. Update policies and procedures as needed to reflect changes, as applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.

Lack of Documentation Related to Reporting (prior two years 2020-104 and 2019-106) (initially reported 2018) Assistance Listing Number: 93.224 and 93.527 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) and Grants for New and Expanded Services Under the Health Center Program Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021) and COVID-19 ARP H8FCS40324 -01(2021) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation in support of reporting requirements. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: Supporting records used to populate the Uniform Data System (UDS) report were not retained by the Organization. Effect: The Organization could submit incorrect information. Recommendation: Documentation should be prepared, reviewed, and retained to support the reporting. The documentation should clearly document who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Action: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization

Lack of Controls Related to Filing Reports (initially reported 2021) Assistance Listing Number: 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: COVID-19 Provider Relief Fund Compliance Requirement: Reporting Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Also under compliance requirements for reporting 2 CFR 200.328 states that information must be collected with the frequency required by the terms and conditions of the federal award for effective monitoring of the federal awards. Cause: The Organization did not have a process in place for review of the data being reported on the HRSA website for the funds being expensed under the Provider Relief Fund program. Effect: The Organization could submit incorrect information. Recommendation: The documentation should be kept that clearly documents who prepared the information, who reviewed the information, and that the reviewer considered whether the information was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its reporting policy and implemented the changes. The corrective action for this finding has been approved and implemented by the Organization.

Use of Budgeted Versus Actual Costs for Reimbursements (prior year 2020-106) (initially reported 2020) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities, Allowable Costs and Period of Performance Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Material Weakness in Internal Control Known Questioned Costs: $0 Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. In addition, based on grant compliance requirements related to allowable activities costs and period of performance, direct costs are those costs that can be specifically identified with a particular actual cost. Cause: Reimbursement was requested based on the budgeted payroll expenditures made for a particular period, adjusted to exclude certain employees that are not related to the grant or are highly paid employees to be conservative in the calculation. Adequate documentation was not maintained and no indication of a review process involved beyond the CFO preparing the calculation to request reimbursement and making the request from the grantor. Effect: The Organization could request funds that may not have adequate supporting documentation. These errors could lead to the Organization losing funding under this program. Recommendation: Documentation should be provided that directly links the amount requested to the related expenditures to clearly document those funds are being used in a timely manner, that more was not requested than was expended, specifically what expenditures are being considered expended through these funds, and that funds requested applied to the correct period. Update policies and procedures as needed to reflect changes, if applicable. Views of Responsible Officials and Planned Corrective Actions: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization.

Missing Documentation to Support Payroll Authorizations (prior year 2019-101, not testable during 2020) (initially reported 2019) Assistance Listing Number: 93.224, 93.527 and 93.498 Name of Federal Agency: Department of Health and Human Services, HRSA Program Title: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) , Grants for New and Expanded Services Under the Health Center Program and COVID-19 Provider Relief Fund Compliance Requirement: Allowable Activities and Costs Pass-through Entity: N/A Federal Grant/Contract Number and Grant Year: H80CS06452-15 (2020), H80CS06452-16 (2021), COVID-19 ARP H8FCS40324 -01(2021) and COVID-19 Provider Relief Fund (2020) Finding Type: Significant Deficiency in Internal Control Known Questioned Costs: $0 Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Criteria: 2 CFR section 200.303 requires that nonfederal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the nonfederal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Under compliance requirements for allowable activities and costs, management should ensure that costs can be supported by underlying accounting documentation. Cause: Filing errors resulting in staff being unable to provide the requested authorizations. Effect: The Organization would not be able to provide the related documentation to support allowable activities and costs under the program which could lead to a loss of grant funding. Recommendation: The Organization should put in a process to appropriately retain documentation to support allowable activities and costs under applicable grant programs. Views of Responsible Officials and Planned Corrective Action: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023.