FAC Explorer

Audit 321244

FY End
2023-12-31
Total Expended
$5.40M
Findings
8
Programs
7
Organization: Brooklyn Plaza Medical Center, Inc. (NY)
Year: 2023 Accepted: 2024-09-26
Auditor: Cohnreznick LLP

Organization Exclusion Status:

Findings

ID Ref Severity Repeat Requirement
498513 2023-001 Material Weakness Yes N
498514 2023-001 Material Weakness Yes N
498515 2023-001 Material Weakness Yes N
498516 2023-001 Material Weakness Yes N
1074955 2023-001 Material Weakness Yes N
1074956 2023-001 Material Weakness Yes N
1074957 2023-001 Material Weakness Yes N
1074958 2023-001 Material Weakness Yes N

Programs

ALN Program Spent Major Findings
93.914 Hiv Emergency Relief Project Grants $488,343 - 0
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $192,189 - 0
93.268 Immunization Cooperative Agreements $113,117 - 0
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $81,180 Yes 1
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $25,053 - 0
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $14,357 Yes 1
93.994 Maternal and Child Health Services Block Grant to the States $6,810 - 0

Contacts

Name Title Type
YRNRHJ1N6W95 Philip Onorato Auditee
7185969800 Gil Bernhard Auditor
No contacts on file

Notes to SEFA

Title: Note 1 - Basis of presentation Accounting Policies: 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 Center has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. The accompanying schedule of expenditures of federal awards (the "Schedule") includes the federal award activities of Brooklyn Plaza Medical Center, Inc. (the "Center") under programs of the federal government for the year ended December 31, 2023. 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 (the "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, change in net assets, or cash flows of the Center.
Title: Note 3 - Donated and nonmonetary assistance Accounting Policies: 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 Center has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. Donated and nonmonetary assistance is reported in the Schedule at the fair value of the vaccinations received. The total federal share of vaccinations distributed by the Center amounted to $113,117. This amount is included on the Schedule.
Title: Note 4 - COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - Assistance Listing Number 93.498 Accounting Policies: 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 Center has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. For the HHS awards related to the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) program, HHS has indicated the amounts on the schedule be reported corresponding to reporting requirements of the HRSA PRF Reporting Portal. Payments from HHS for PRF are assigned to 'Payment Received Periods' (each, a Period) based upon the date each payment from the PRF was received. Each Period has a specified Period of Availability and timing of reporting requirements. Entities report into the HRSA PRF Reporting Portal after each Period's deadline to use the funds (i.e., after the end of the Period of Availability). The schedule includes $25,053 received from HHS on January 26, 2022. In accordance with guidance from HHS, this amount represents $25,053 for Period 5 and was recognized as DHHS grant revenue in the financial statements for the year ended December 31, 2022.

Finding Details

Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.
Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.
Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.
Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.
Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.
Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.
Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.
Finding 2023-001
Section III - Federal Award Findings and Questioned Costs U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Item 2023-001 - Special Tests and Provisions Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended December 31, 2023. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of twenty-four patients selected for testing based on the sliding fee scale in effect for the year ended December 31, 2023. For two of these patients, there was no supporting documentation on file to support the sliding fee discount provided. Identification as a Repeat Finding Condition is a repeat finding - see 2022-001. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official As part of the corrective action plan for this finding, the Center hired a consulting firm in September 2023 to perform a comprehensive review of the Center's electronic medical record system to ensure that the system setup is correct and that proper reports are being generated. In addition, the consulting firm is training all front desk staff, including the director and supervisors and conducting bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. Lastly, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program.