Audit 34825

FY End
2022-06-30
Total Expended
$1.89M
Findings
12
Programs
7
Year: 2022 Accepted: 2023-03-30
Auditor: Sbng PC

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
36903 2022-001 Significant Deficiency Yes N
36904 2022-001 Significant Deficiency Yes N
36905 2022-001 Significant Deficiency Yes N
36906 2022-001 Significant Deficiency Yes N
36907 2022-001 Significant Deficiency Yes N
36908 2022-001 Significant Deficiency Yes N
613345 2022-001 Significant Deficiency Yes N
613346 2022-001 Significant Deficiency Yes N
613347 2022-001 Significant Deficiency Yes N
613348 2022-001 Significant Deficiency Yes N
613349 2022-001 Significant Deficiency Yes N
613350 2022-001 Significant Deficiency Yes N

Contacts

Name Title Type
NJPJB9HGR7B5 Pamela Angell Auditee
5755275482 Joanne Nugent Auditor
No contacts on file

Notes to SEFA

Accounting Policies: This summary of significant accounting policies of St. Lukes Health Care Clinic, Inc. ispresented to assist in understanding St. Lukes Health Care Clinic, Inc.s Schedule of Expenditures ofFederal Awards. The Schedule and notes are representations of St. Lukes Health Care Clinic, Inc.smanagement, who is responsible for their integrity and objectivity.Basis of Accounting and Presentation The Schedule of Expenditures of Federal Awards isprepared using the accrual basis of accounting. The information in the schedule is presented in accordancewith the Uniform Guidance; therefore, some amounts presented in this schedule may differ from amountspresented in, or used in the preparation of, the basic financial statements.Indirect Costs Expenditures of federal awards may include a portion of costs associated withgeneral and administrative activities, which are allocated to federal assistance programs under negotiatedformulas, commonly referred to as indirect cost rates and federally approved cost allocation plans. TheOrganizations only indirect cost expenses charged to federal awards consist of administrative salariesand payments to administrative consultants, which are allocated to various programs based on time andeffort records. The allocation methods have been approved by each awarding agency. The Organizationhas not negotiated an indirect rate with its federal cognizant agency and has not elected to use thede minimis rate of 10% of modified total direct cost as an indirect cost allocation factor, as allowed under2 CFR ?200.414.Sub-Recipients There were no sub-recipients of the federal awards received by St. LukesHealth Care Clinic, Inc. for the year ended June 30, 2022. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate.

Finding Details

Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.
Criteria: The Health Center Program Compliance Manual requires that a health center establish systems for sliding fee eligibility determination. The Organization should implement procedures that include assessing and re-assessing all patients for income and family size consistent with board-approved policies and poverty guidelines, including the maintenance of related records of such assessments. Condition: During our procedures on the application of the sliding fee, it was noted that 2 out of 53 patients tested were placed on the incorrect sliding fee based on available information regarding the individual?s income. For 1 patient out of 53, no documentation was maintained supporting sliding fee placement. Cause: The Organization began training intake staff on policies regarding application of sliding fees during the fiscal year under audit; however, corrective action was not fully implemented due to lack of time. Effect: In addition to charging an incorrect fee or no fee to the patient, a condition could be placed on the grant?s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management continue providing trainings to intake personnel to ensure that patients are placed on the correct sliding fee category based on information provided upon admission and that the fee determination is reviewed and updated as needed. Management?s response: Management agrees with auditor recommendation. Refer to Corrective Action Plan for expected date of completion.