Audit 320390

FY End
2023-12-31
Total Expended
$2.39M
Findings
6
Programs
6
Year: 2023 Accepted: 2024-09-23
Auditor: Bonadio & CO LLP

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
497616 2023-002 Significant Deficiency - N
497617 2023-002 Significant Deficiency - N
497618 2023-002 Significant Deficiency - N
1074058 2023-002 Significant Deficiency - N
1074059 2023-002 Significant Deficiency - N
1074060 2023-002 Significant Deficiency - N

Contacts

Name Title Type
QMRBCR6KBBV4 Jose Virella Auditee
2127697245 Karen Lynch Auditor
No contacts on file

Notes to SEFA

Title: Non-Cash Awards Accounting Policies: 1.BASIS OF PRESENTATION: The accompanying schedule of expenditures of federal awards (the Schedule) summarizes the expenditures of Ryan/Chelsea-Clinton Community Health Center, Inc. (The Center) under programs of the federal government for the year ended December 31, 2023, and has been prepared in conformity with accounting principles generally accepted in the United States. The information in this schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Because the schedule presents only a selected portion of the operations of The Center, it is not intended to and does not present the financial position, changes in net assets, or cash flows of The Center. 2.BASIS OF ACCOUNTING: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. De Minimis Rate Used: N Rate Explanation: The auditee does not use De Minimis cost rate. The Center received noncash assistance of $713,334 in the form of immunization vaccines for Federal Assistance Listing number 93.268 during the year ended December 31, 2023, which were passed through the City of New York Department of Health and Mental Hygiene. Distribution of the immunizations is reflected in the Schedule.

Finding Details

Finding 2023-002 – Health Centers Cluster Federal Agency – U.S. Department of Health and Human Services Grant Period – Year ended December 31, 2023 Criteria - Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The health center must demonstrate adjustments to charges are consistent with the health center’s SFDS. Condition - We attempted to recalculate the applied discount using the Center’s policy and the patient documentation provided, noting instances where the adjustments to charges were inconsistent with the Center’s SFDS. Cause - Lack of controls to ensure that staff are obtaining required documentation and entering the information correctly. Effect - Out of our sample of 20 selections, we identified five exceptions based on the SFDS. Three of the discounts entered lacked the required slide documentation, the slide form had expired and was not updated, or the document was updated, but the data in the system was not resulting in the slide that was provided not being supported or applied incorrectly. Two of the discounts were improperly adjusted during the billing or review process based on insurance or payments received, or incorrect charges being calculated and applied to the total slide for the remaining patient balance. Recommendation - Providing the sliding fee to patients is a requirement of specific grant funds received. As such, we recommend the Center review the current procedures in place and consider additional and more frequent training for all employees involved in the process. We encourage management to consider appointing an individual at the various locations to assist the front desk staff with the sliding fee process to ensure required documentation is captured and recorded accurately in the billing system. We also encourage the Center to consider assigning a dedicated individual to regularly review the sliding fee visits to ensure compliance. This should be someone who is knowledgeable of the sliding fee requirements and the Center’s billing processes and procedures.
Finding 2023-002 – Health Centers Cluster Federal Agency – U.S. Department of Health and Human Services Grant Period – Year ended December 31, 2023 Criteria - Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The health center must demonstrate adjustments to charges are consistent with the health center’s SFDS. Condition - We attempted to recalculate the applied discount using the Center’s policy and the patient documentation provided, noting instances where the adjustments to charges were inconsistent with the Center’s SFDS. Cause - Lack of controls to ensure that staff are obtaining required documentation and entering the information correctly. Effect - Out of our sample of 20 selections, we identified five exceptions based on the SFDS. Three of the discounts entered lacked the required slide documentation, the slide form had expired and was not updated, or the document was updated, but the data in the system was not resulting in the slide that was provided not being supported or applied incorrectly. Two of the discounts were improperly adjusted during the billing or review process based on insurance or payments received, or incorrect charges being calculated and applied to the total slide for the remaining patient balance. Recommendation - Providing the sliding fee to patients is a requirement of specific grant funds received. As such, we recommend the Center review the current procedures in place and consider additional and more frequent training for all employees involved in the process. We encourage management to consider appointing an individual at the various locations to assist the front desk staff with the sliding fee process to ensure required documentation is captured and recorded accurately in the billing system. We also encourage the Center to consider assigning a dedicated individual to regularly review the sliding fee visits to ensure compliance. This should be someone who is knowledgeable of the sliding fee requirements and the Center’s billing processes and procedures.
Finding 2023-002 – Health Centers Cluster Federal Agency – U.S. Department of Health and Human Services Grant Period – Year ended December 31, 2023 Criteria - Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The health center must demonstrate adjustments to charges are consistent with the health center’s SFDS. Condition - We attempted to recalculate the applied discount using the Center’s policy and the patient documentation provided, noting instances where the adjustments to charges were inconsistent with the Center’s SFDS. Cause - Lack of controls to ensure that staff are obtaining required documentation and entering the information correctly. Effect - Out of our sample of 20 selections, we identified five exceptions based on the SFDS. Three of the discounts entered lacked the required slide documentation, the slide form had expired and was not updated, or the document was updated, but the data in the system was not resulting in the slide that was provided not being supported or applied incorrectly. Two of the discounts were improperly adjusted during the billing or review process based on insurance or payments received, or incorrect charges being calculated and applied to the total slide for the remaining patient balance. Recommendation - Providing the sliding fee to patients is a requirement of specific grant funds received. As such, we recommend the Center review the current procedures in place and consider additional and more frequent training for all employees involved in the process. We encourage management to consider appointing an individual at the various locations to assist the front desk staff with the sliding fee process to ensure required documentation is captured and recorded accurately in the billing system. We also encourage the Center to consider assigning a dedicated individual to regularly review the sliding fee visits to ensure compliance. This should be someone who is knowledgeable of the sliding fee requirements and the Center’s billing processes and procedures.
Finding 2023-002 – Health Centers Cluster Federal Agency – U.S. Department of Health and Human Services Grant Period – Year ended December 31, 2023 Criteria - Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The health center must demonstrate adjustments to charges are consistent with the health center’s SFDS. Condition - We attempted to recalculate the applied discount using the Center’s policy and the patient documentation provided, noting instances where the adjustments to charges were inconsistent with the Center’s SFDS. Cause - Lack of controls to ensure that staff are obtaining required documentation and entering the information correctly. Effect - Out of our sample of 20 selections, we identified five exceptions based on the SFDS. Three of the discounts entered lacked the required slide documentation, the slide form had expired and was not updated, or the document was updated, but the data in the system was not resulting in the slide that was provided not being supported or applied incorrectly. Two of the discounts were improperly adjusted during the billing or review process based on insurance or payments received, or incorrect charges being calculated and applied to the total slide for the remaining patient balance. Recommendation - Providing the sliding fee to patients is a requirement of specific grant funds received. As such, we recommend the Center review the current procedures in place and consider additional and more frequent training for all employees involved in the process. We encourage management to consider appointing an individual at the various locations to assist the front desk staff with the sliding fee process to ensure required documentation is captured and recorded accurately in the billing system. We also encourage the Center to consider assigning a dedicated individual to regularly review the sliding fee visits to ensure compliance. This should be someone who is knowledgeable of the sliding fee requirements and the Center’s billing processes and procedures.
Finding 2023-002 – Health Centers Cluster Federal Agency – U.S. Department of Health and Human Services Grant Period – Year ended December 31, 2023 Criteria - Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The health center must demonstrate adjustments to charges are consistent with the health center’s SFDS. Condition - We attempted to recalculate the applied discount using the Center’s policy and the patient documentation provided, noting instances where the adjustments to charges were inconsistent with the Center’s SFDS. Cause - Lack of controls to ensure that staff are obtaining required documentation and entering the information correctly. Effect - Out of our sample of 20 selections, we identified five exceptions based on the SFDS. Three of the discounts entered lacked the required slide documentation, the slide form had expired and was not updated, or the document was updated, but the data in the system was not resulting in the slide that was provided not being supported or applied incorrectly. Two of the discounts were improperly adjusted during the billing or review process based on insurance or payments received, or incorrect charges being calculated and applied to the total slide for the remaining patient balance. Recommendation - Providing the sliding fee to patients is a requirement of specific grant funds received. As such, we recommend the Center review the current procedures in place and consider additional and more frequent training for all employees involved in the process. We encourage management to consider appointing an individual at the various locations to assist the front desk staff with the sliding fee process to ensure required documentation is captured and recorded accurately in the billing system. We also encourage the Center to consider assigning a dedicated individual to regularly review the sliding fee visits to ensure compliance. This should be someone who is knowledgeable of the sliding fee requirements and the Center’s billing processes and procedures.
Finding 2023-002 – Health Centers Cluster Federal Agency – U.S. Department of Health and Human Services Grant Period – Year ended December 31, 2023 Criteria - Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The health center must demonstrate adjustments to charges are consistent with the health center’s SFDS. Condition - We attempted to recalculate the applied discount using the Center’s policy and the patient documentation provided, noting instances where the adjustments to charges were inconsistent with the Center’s SFDS. Cause - Lack of controls to ensure that staff are obtaining required documentation and entering the information correctly. Effect - Out of our sample of 20 selections, we identified five exceptions based on the SFDS. Three of the discounts entered lacked the required slide documentation, the slide form had expired and was not updated, or the document was updated, but the data in the system was not resulting in the slide that was provided not being supported or applied incorrectly. Two of the discounts were improperly adjusted during the billing or review process based on insurance or payments received, or incorrect charges being calculated and applied to the total slide for the remaining patient balance. Recommendation - Providing the sliding fee to patients is a requirement of specific grant funds received. As such, we recommend the Center review the current procedures in place and consider additional and more frequent training for all employees involved in the process. We encourage management to consider appointing an individual at the various locations to assist the front desk staff with the sliding fee process to ensure required documentation is captured and recorded accurately in the billing system. We also encourage the Center to consider assigning a dedicated individual to regularly review the sliding fee visits to ensure compliance. This should be someone who is knowledgeable of the sliding fee requirements and the Center’s billing processes and procedures.