Audit 343418

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.002: Eligibility - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: HIV Emergency Relief Project Grants Federal Assistance Listing Numbers: 93.914 Federal Award Identification Number and Year: A23-0249 – 2024 Name of Pass-through Entity: City of New Haven Criteria In accordance with 2CFR 200.303(a), Internal Controls, a non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The specific eligibility requirements are unique to each Federal program, in accordance with the terms and conditions of the Federal award pertaining to the program. Condition During our testing over eligibility requirements, we were unable to review sufficient documentation to support that benefit recipients were eligible for benefits. Cause The Organization’s internal controls over eligibility were not consistently followed to ensure the presence of documentation to support that all benefit recipients were eligible for benefits. Effect or Potential Effect Lack of sufficient support over eligibility could result in ineligible individuals receiving benefits. Questioned Costs None. Context We selected 40 beneficiaries charged to the federal program to test compliance and controls over eligibility. Out of the 40 individuals tested, we noted 2 instances where there was no documentation to support that benefit recipients were eligible for benefits and the internal controls over eligibility were followed. Identification of Repeat Finding None. Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Community Health Centers COVID-19 Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H800350 - 2023 and 2024, H8F41047 - 2021, H8G47675 - 2022, H8L51773 - 2023 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. Condition The Center did not always calculate the proper sliding fee discount based on approved policies. Cause The Center did not have adequate internal controls in place to effectively ensure that the patients received the correct sliding fee discount. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in four instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statically valid sample. Identification of Repeat Finding Yes - 2023.001. Recommendation The Center should establish a system of controls to ensure that all patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.002: Eligibility - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: HIV Emergency Relief Project Grants Federal Assistance Listing Numbers: 93.914 Federal Award Identification Number and Year: A23-0249 – 2024 Name of Pass-through Entity: City of New Haven Criteria In accordance with 2CFR 200.303(a), Internal Controls, a non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The specific eligibility requirements are unique to each Federal program, in accordance with the terms and conditions of the Federal award pertaining to the program. Condition During our testing over eligibility requirements, we were unable to review sufficient documentation to support that benefit recipients were eligible for benefits. Cause The Organization’s internal controls over eligibility were not consistently followed to ensure the presence of documentation to support that all benefit recipients were eligible for benefits. Effect or Potential Effect Lack of sufficient support over eligibility could result in ineligible individuals receiving benefits. Questioned Costs None. Context We selected 40 beneficiaries charged to the federal program to test compliance and controls over eligibility. Out of the 40 individuals tested, we noted 2 instances where there was no documentation to support that benefit recipients were eligible for benefits and the internal controls over eligibility were followed. Identification of Repeat Finding None. Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.