Finding: 2024-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain 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 employees and certain 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 policies and 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 establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain 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 employees and certain 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 policies and 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 establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-003 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 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 are required to document sliding fee discounts in accordance with the Organization’s policies. During compliance testing, it was determined that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing.
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 from the patients, and that the resulting sliding fee discounts were correctly calculated in accordance with the Organization’s sliding fee policy.
Effect: Documentation to substantiate discounts applied to certain patient accounts was not available for certain sliding fee patient visits during the year.
Questioned Costs: None
Context/Sampling: For 18 of 48 patients selected for testing, sliding fee applications were incomplete, missing, or expired. 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 be trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. It is also recommended that patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-003 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 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 are required to document sliding fee discounts in accordance with the Organization’s policies. During compliance testing, it was determined that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing.
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 from the patients, and that the resulting sliding fee discounts were correctly calculated in accordance with the Organization’s sliding fee policy.
Effect: Documentation to substantiate discounts applied to certain patient accounts was not available for certain sliding fee patient visits during the year.
Questioned Costs: None
Context/Sampling: For 18 of 48 patients selected for testing, sliding fee applications were incomplete, missing, or expired. 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 be trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. It is also recommended that patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. 93.527
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) are not maintained for salaried employees as required by federal cost principles.
Cause: The Organization’s policy does not require that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis).
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for salaried employees were not maintained. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its policies to ensure that the policies require personnel to document time and efforts in accordance with federal cost principles. Procedures should subsequently be established to ensure that all salaried employees maintain time and effort reports in accordance with the revised policy. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be established to ensure that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. 93.527
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) are not maintained for salaried employees as required by federal cost principles.
Cause: The Organization’s policy does not require that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis).
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for salaried employees were not maintained. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its policies to ensure that the policies require personnel to document time and efforts in accordance with federal cost principles. Procedures should subsequently be established to ensure that all salaried employees maintain time and effort reports in accordance with the revised policy. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be established to ensure that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain 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 employees and certain 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 policies and 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 establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-002 Procurement, Suspension, and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not verify that employees and certain 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 employees and certain 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 policies and 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 establish policies and procedures to ensure that employees and vendors are not suspended, debarred or otherwise excluded from participating in federal programs.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-003 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 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 are required to document sliding fee discounts in accordance with the Organization’s policies. During compliance testing, it was determined that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing.
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 from the patients, and that the resulting sliding fee discounts were correctly calculated in accordance with the Organization’s sliding fee policy.
Effect: Documentation to substantiate discounts applied to certain patient accounts was not available for certain sliding fee patient visits during the year.
Questioned Costs: None
Context/Sampling: For 18 of 48 patients selected for testing, sliding fee applications were incomplete, missing, or expired. 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 be trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. It is also recommended that patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-003 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 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 are required to document sliding fee discounts in accordance with the Organization’s policies. During compliance testing, it was determined that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing.
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 from the patients, and that the resulting sliding fee discounts were correctly calculated in accordance with the Organization’s sliding fee policy.
Effect: Documentation to substantiate discounts applied to certain patient accounts was not available for certain sliding fee patient visits during the year.
Questioned Costs: None
Context/Sampling: For 18 of 48 patients selected for testing, sliding fee applications were incomplete, missing, or expired. 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 be trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. It is also recommended that patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. 93.527
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) are not maintained for salaried employees as required by federal cost principles.
Cause: The Organization’s policy does not require that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis).
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for salaried employees were not maintained. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its policies to ensure that the policies require personnel to document time and efforts in accordance with federal cost principles. Procedures should subsequently be established to ensure that all salaried employees maintain time and effort reports in accordance with the revised policy. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be established to ensure that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024
Finding: 2024-004 Monthly Time/Activity Reports not Maintained for Salaried Employees
Federal Program Identification: U.S. Department of Health and Human Services
Health Center Cluster
Assistance Listing No. 93.527
Criteria: Uniform Guidance Compliance Supplement, Grant Policy Statements, 45 CFR, 75.430
Condition: Time/activity reports (time sheets) are not maintained for salaried employees as required by federal cost principles.
Cause: The Organization’s policy does not require that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis).
Effect: Failure to comply with federal requirements regarding personnel cost and time and effort could result in a reduction of grant funds.
Questioned Costs: None
Context/Sampling: A test of payroll disbursements revealed that time and effort certifications for salaried employees were not maintained. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: No
Recommendation: The Organization should evaluate and revise its policies to ensure that the policies require personnel to document time and efforts in accordance with federal cost principles. Procedures should subsequently be established to ensure that all salaried employees maintain time and effort reports in accordance with the revised policy. It is recommended that time and effort certifications be prepared no less than monthly and coincide with the Organization’s payroll cycle.
Views of Responsible Officials: Policies and procedures will be established to ensure that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle.
Contact Person: Mark Rajkowski, CEO
Anticipated Date of Completion: October 31, 2024