Audit 330347

FY End
2024-06-30
Total Expended
$2.53M
Findings
12
Programs
7
Year: 2024 Accepted: 2024-12-02
Auditor: Terry Horne CPA

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
512518 2024-002 Material Weakness Yes N
512519 2024-002 Material Weakness Yes N
512520 2024-002 Material Weakness Yes N
512521 2024-003 Material Weakness - C
512522 2024-003 Material Weakness - C
512523 2024-003 Material Weakness - C
1088960 2024-002 Material Weakness Yes N
1088961 2024-002 Material Weakness Yes N
1088962 2024-002 Material Weakness Yes N
1088963 2024-003 Material Weakness - C
1088964 2024-003 Material Weakness - C
1088965 2024-003 Material Weakness - C

Contacts

Name Title Type
Y3DJYKS5KDF5 Shantelle Simpson Auditee
8283543402 Terry Horne Auditor
No contacts on file

Notes to SEFA

Title: 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. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The Organization has elected not to use the 10 percent de minimus indirect cost rate allowed under Uniform Guidance. De Minimis Rate Used: N Rate Explanation: N/A Basis of presentation described
Title: Subrecipients 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. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The Organization has elected not to use the 10 percent de minimus indirect cost rate allowed under Uniform Guidance. De Minimis Rate Used: N Rate Explanation: N/A Statement regarding use of subrecipients

Finding Details

Finding: 2024-002 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 receiving 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 the following errors were noted: • 9 patients were given discounts when applications were incomplete or expired • 3 patients who qualified for discounts were given an incorrect discount • 1 patient with income greater than 200% poverty was given a discount • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 14 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. 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: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-002 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 receiving 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 the following errors were noted: • 9 patients were given discounts when applications were incomplete or expired • 3 patients who qualified for discounts were given an incorrect discount • 1 patient with income greater than 200% poverty was given a discount • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 14 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. 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: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-002 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 receiving 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 the following errors were noted: • 9 patients were given discounts when applications were incomplete or expired • 3 patients who qualified for discounts were given an incorrect discount • 1 patient with income greater than 200% poverty was given a discount • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 14 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. 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: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-003 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 three draws of federal funds that were 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 draws of federal grant funds in advance of making the qualifying expenditures. Effect: Although expenditures were made prior to June 30, 2024, the Organization did not minimize the time elapsing between transfer of funds from the United States Treasury and the disbursement for expenditures. 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. 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. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-003 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 three draws of federal funds that were 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 draws of federal grant funds in advance of making the qualifying expenditures. Effect: Although expenditures were made prior to June 30, 2024, the Organization did not minimize the time elapsing between transfer of funds from the United States Treasury and the disbursement for expenditures. 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. 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. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-003 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 three draws of federal funds that were 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 draws of federal grant funds in advance of making the qualifying expenditures. Effect: Although expenditures were made prior to June 30, 2024, the Organization did not minimize the time elapsing between transfer of funds from the United States Treasury and the disbursement for expenditures. 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. 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. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-002 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 receiving 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 the following errors were noted: • 9 patients were given discounts when applications were incomplete or expired • 3 patients who qualified for discounts were given an incorrect discount • 1 patient with income greater than 200% poverty was given a discount • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 14 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. 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: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-002 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 receiving 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 the following errors were noted: • 9 patients were given discounts when applications were incomplete or expired • 3 patients who qualified for discounts were given an incorrect discount • 1 patient with income greater than 200% poverty was given a discount • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 14 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. 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: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-002 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 receiving 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 the following errors were noted: • 9 patients were given discounts when applications were incomplete or expired • 3 patients who qualified for discounts were given an incorrect discount • 1 patient with income greater than 200% poverty was given a discount • 1 patient with income less than 200% poverty was not given a discount Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 14 of 48 self-pay patients selected for testing, applications were incomplete or expired or incorrect discounts were given. 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: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is obtained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-003 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 three draws of federal funds that were 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 draws of federal grant funds in advance of making the qualifying expenditures. Effect: Although expenditures were made prior to June 30, 2024, the Organization did not minimize the time elapsing between transfer of funds from the United States Treasury and the disbursement for expenditures. 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. 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. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-003 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 three draws of federal funds that were 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 draws of federal grant funds in advance of making the qualifying expenditures. Effect: Although expenditures were made prior to June 30, 2024, the Organization did not minimize the time elapsing between transfer of funds from the United States Treasury and the disbursement for expenditures. 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. 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. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025
Finding: 2024-003 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 three draws of federal funds that were 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 draws of federal grant funds in advance of making the qualifying expenditures. Effect: Although expenditures were made prior to June 30, 2024, the Organization did not minimize the time elapsing between transfer of funds from the United States Treasury and the disbursement for expenditures. 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. 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. Contact Person: Shantelle Simpson, President & CEO Anticipated Date of Completion: January 31, 2025