Finding: 2023-004 Reporting
Federal Programs: Department of Health and Human Services (DHHS)
Grants for Capital Development in Health Centers
Assistance Listing No. - 93.526
Criteria: Uniform Guidance, Reporting – Federal Financial Report
Condition: A Federal Financial Report (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2023, for the Organization’s federal grant C8ECS44212, contained incorrect data related to the Organization’s federal share of expenditures. The FFR filing reported an incorrect unobligated balance at the related reporting period end date.
Cause: The Organization used incorrect data to complete and submit a FFR during the fiscal year ended December 31, 2023.
Effect: The unobligated balance reported to DHHS was overstated by approximately $720,000.
Questioned Costs: None reported
Context/Sampling: FFR filings are reviewed as part of the audit. Given that there was a filing with errors, the finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the FFR for any Federal grant is reviewed by a person other than the preparer of the report prior to submission.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFRs are reviewed by a person other than the preparer prior to submission to DHHS.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-004 Reporting
Federal Programs: Department of Health and Human Services (DHHS)
Grants for Capital Development in Health Centers
Assistance Listing No. - 93.526
Criteria: Uniform Guidance, Reporting – Federal Financial Report
Condition: A Federal Financial Report (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2023, for the Organization’s federal grant C8ECS44212, contained incorrect data related to the Organization’s federal share of expenditures. The FFR filing reported an incorrect unobligated balance at the related reporting period end date.
Cause: The Organization used incorrect data to complete and submit a FFR during the fiscal year ended December 31, 2023.
Effect: The unobligated balance reported to DHHS was overstated by approximately $720,000.
Questioned Costs: None reported
Context/Sampling: FFR filings are reviewed as part of the audit. Given that there was a filing with errors, the finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the FFR for any Federal grant is reviewed by a person other than the preparer of the report prior to submission.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFRs are reviewed by a person other than the preparer prior to submission to DHHS.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-005 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: During the year, the Organization made an advance draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes.
Cause: The Organization made a draw of federal grant funds in advance of making the qualifying expenditures.
Effect: Qualifying federal expenditures were not made by the Organization, resulting in excess federal funds drawn of $71,520.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur, and excess federal funds should be returned to the Department of Health and Human Services.
Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-006 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required.
Effect: The Organization did not verify that certain employees and vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required.
Views of Responsible Officials: Management concurs. Management will verify that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-007 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds.
Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024
Finding: 2023-008 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 9 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected had an no application or an incomplete application, three patients received an incorrect discount, one patient received a discount who did not qualify for a discount, and one patient who qualified for a discount was not provided a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2024