Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award No. 6 H80CS26514-04-00
Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles - 45 CFR 75.403(g) and Period of Performance - 45 CFR 75.309.
Condition – The Organization is required to maintain a system of internal control over compliance to ensure expenditures applied to federal awards are allowable, meet Federal cost principles, and fall within the period of performance.
Context - The Organization was subject to a limited scope review by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Financial Integrity. This review examined the Organization's compliance with certain requirements related to the Access Increases in Mental Health and Substance Abuse Services Supplemental Funding (AIMS), which covered a period of from September 1, 2017 through February 28, 2019, following an approved carryover request. The review identified certain expenditures that fell outside the period of performance or were not supported by appropriate documentation.
Questioned Costs - $55,112
Effect - The Organization was not in compliance with the requirements relating to activities allowed or unallowed, allowable costs/cost principles, and period of performance and were required to repay the questioned costs to the granting agency.
Cause - The Organization's policies and procedures did not allow for proper cut-off of expenditures as it applied to the AIMS grant. In addition, the Organization's policies and procedures did not prevent certain costs from being applied to the AIMS grant twice.
Identification as a repeat finding, if applicable - Not a repeat finding.
Recommendation - The Organization should revise its policies and procedures over related to grant expenditures cut-off and tracking to ensure compliant grants management.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Procurement – 45 CFR 75.329
Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards.
Questioned Costs – Unknown
Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list.
Effect – Purchases were made that did not adhere to the Organization’s procurement policy.
Cause – The Organization did not comply with their federal procurement policy.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information.
Questioned Costs – None
Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR.
Effect – Potential errors were made on the annual UDS and annual FFR reports.
Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program.
Identification as a repeat finding, if applicable – Not a repeat finding.
Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Health Center Program Cluster
Assistance Listing Nos. 93.224 and 93.527
U.S Department of Health and Human Services
Award No. 6 H80CS26514-04-00
Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles - 45 CFR 75.403(g) and Period of Performance - 45 CFR 75.309.
Condition – The Organization is required to maintain a system of internal control over compliance to ensure expenditures applied to federal awards are allowable, meet Federal cost principles, and fall within the period of performance.
Context - The Organization was subject to a limited scope review by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Financial Integrity. This review examined the Organization's compliance with certain requirements related to the Access Increases in Mental Health and Substance Abuse Services Supplemental Funding (AIMS), which covered a period of from September 1, 2017 through February 28, 2019, following an approved carryover request. The review identified certain expenditures that fell outside the period of performance or were not supported by appropriate documentation.
Questioned Costs - $55,112
Effect - The Organization was not in compliance with the requirements relating to activities allowed or unallowed, allowable costs/cost principles, and period of performance and were required to repay the questioned costs to the granting agency.
Cause - The Organization's policies and procedures did not allow for proper cut-off of expenditures as it applied to the AIMS grant. In addition, the Organization's policies and procedures did not prevent certain costs from being applied to the AIMS grant twice.
Identification as a repeat finding, if applicable - Not a repeat finding.
Recommendation - The Organization should revise its policies and procedures over related to grant expenditures cut-off and tracking to ensure compliant grants management.