Audit 334705

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-002 Preparation of the Schedule Expenditures of Federal Awards -Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: The Uniform Guidance (2 CFR 200) Section 200.510 requires an auditee to “prepare a schedule of expenditures of Federal awards (SEFA) for the period covered by the auditee’s financial statements [that]….at a minimum shall…list individual Federal programs by Federal agency…[and] provide total Federal awards expended for each individual Federal program and the Assistance Listing Number (ALN) number or other identifying number when the ALN information is not available.” In accordance with Uniform Guidance, the Organization is required to maintain a structure of internal control to ensure compliance with applicable reporting requirements. Condition/Cause: The Health Center did not have sufficient controls to ensure the SEFA included all expenditures that qualified as an expenditure of a federal award during the period. Effect: The total expenditures presented per the preliminary SEFA increased by $4,800,000 related to ALN #21.027, Coronavirus State and Local Fiscal Recovery Funds, which resulted in an additional major program. No changes to the other financial statements were needed and the final SEFA was corrected to reflect the change. Questioned Costs: Not applicable. Context: Factors contributing to the condition included the high volume of activity related to new COVID-19 programs and the lack of understanding that the related payments represented grant expenditures from a Federal source that were required to be reported on the SEFA as opposed to grant payments from a non-federal source. Repeat Finding: Not applicable. Recommendation: We recommend the Health Center develop and implement a review process through the year to ensure compliance with SEFA reporting requirements as outlined in the Uniform Guidance. Views of Responsible Officials: Processes will be put in place to compile the SEFA, provide adequete training to staff, and perform a related review prior to audit. In addition, grant agreements will be thoroughly reviewed.

Finding 2024-003 Timely Reporting of Coronavirus State and Local Fiscal Recovery Funds – Significant Deficiency in Internal Controls over Compliance Program: U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: Per the guidelines established by the U.S. Department of the Treasury and the Washington State Healthcare Authority (HCA), recipients of the Coronavirus State and Local Fiscal Recovery Funds are required to submit financial and programmatic reports within specified deadlines to ensure accountability and compliance with federal and state regulations. Condition/Cause: The Health Center did not submit the required annual report related to the Coronavirus State and Local Fiscal Recovery Funds to the Washington State Healthcare Authority within the mandated timeframe. Specifically, the Health Center submitted the report 16 days past the due date. Effect: The failure to submit reports by the deadlines could impact the funding agencies ability to monitor in a timely fashion. Questioned Costs: Not applicable. Context: Factors contributing to the condition included the high volume of activity related to the COVID-19 programs and the Health Center did not have previous experience with the related requirements. Repeat Finding: Not applicable. Recommendation: We recommend the Health Center develop and implement a review process to ensure compliance with reporting requirements as outlined in the Uniform Guidance. Views of Responsible Officials: Processes will be put in place to ensure reporting is completed timely.

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-001 Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Health and Human Services Health Center Program Cluster: ALN 93.224/93.527 Award Number: Various Award Year: 2023, 2024 U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. Condition/Cause: The Health Center had instances in which discounts were not applied accurately based on the underlying support that was provided by the patient. Effect: Certain patients may have been billed amounts in excess of and less than the amounts defined by the sliding fee discount schedule. Questioned Costs: Not applicable. Context: We selected 60 patient visits out of the entire population of patients that may be eligible to receive benefits under the program during the fiscal year ended March 31, 2024. In 2 of the 60 samples tested, the patient did not receive the proper sliding fee scale discount per the Health Center’s policy. Additionally, during our testing of Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027, we noted 1 instance in our testing in which the patient received a sliding fee scale discount after declining the discount. Repeat Finding: Not applicable. Recommendation: We recommend that further processes and training be put in place to ensure that the sliding fee scale is accurately applied to all qualifying program participants and applicable documentation is retained. Views of Responsible Officials: The Health Center concurs with the finding and is working on implementing the recommendation.

Finding 2024-002 Preparation of the Schedule Expenditures of Federal Awards -Significant Deficiency in Internal Control over Compliance Program: U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: The Uniform Guidance (2 CFR 200) Section 200.510 requires an auditee to “prepare a schedule of expenditures of Federal awards (SEFA) for the period covered by the auditee’s financial statements [that]….at a minimum shall…list individual Federal programs by Federal agency…[and] provide total Federal awards expended for each individual Federal program and the Assistance Listing Number (ALN) number or other identifying number when the ALN information is not available.” In accordance with Uniform Guidance, the Organization is required to maintain a structure of internal control to ensure compliance with applicable reporting requirements. Condition/Cause: The Health Center did not have sufficient controls to ensure the SEFA included all expenditures that qualified as an expenditure of a federal award during the period. Effect: The total expenditures presented per the preliminary SEFA increased by $4,800,000 related to ALN #21.027, Coronavirus State and Local Fiscal Recovery Funds, which resulted in an additional major program. No changes to the other financial statements were needed and the final SEFA was corrected to reflect the change. Questioned Costs: Not applicable. Context: Factors contributing to the condition included the high volume of activity related to new COVID-19 programs and the lack of understanding that the related payments represented grant expenditures from a Federal source that were required to be reported on the SEFA as opposed to grant payments from a non-federal source. Repeat Finding: Not applicable. Recommendation: We recommend the Health Center develop and implement a review process through the year to ensure compliance with SEFA reporting requirements as outlined in the Uniform Guidance. Views of Responsible Officials: Processes will be put in place to compile the SEFA, provide adequete training to staff, and perform a related review prior to audit. In addition, grant agreements will be thoroughly reviewed.

Finding 2024-003 Timely Reporting of Coronavirus State and Local Fiscal Recovery Funds – Significant Deficiency in Internal Controls over Compliance Program: U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 Award year: 2022, 2023 Criteria: Per the guidelines established by the U.S. Department of the Treasury and the Washington State Healthcare Authority (HCA), recipients of the Coronavirus State and Local Fiscal Recovery Funds are required to submit financial and programmatic reports within specified deadlines to ensure accountability and compliance with federal and state regulations. Condition/Cause: The Health Center did not submit the required annual report related to the Coronavirus State and Local Fiscal Recovery Funds to the Washington State Healthcare Authority within the mandated timeframe. Specifically, the Health Center submitted the report 16 days past the due date. Effect: The failure to submit reports by the deadlines could impact the funding agencies ability to monitor in a timely fashion. Questioned Costs: Not applicable. Context: Factors contributing to the condition included the high volume of activity related to the COVID-19 programs and the Health Center did not have previous experience with the related requirements. Repeat Finding: Not applicable. Recommendation: We recommend the Health Center develop and implement a review process to ensure compliance with reporting requirements as outlined in the Uniform Guidance. Views of Responsible Officials: Processes will be put in place to ensure reporting is completed timely.