FAC Explorer

Audit 351868

FY End
2024-06-30
Total Expended
$4.68M
Findings
12
Programs
10
Organization: New River Health Association, Inc. (WV)
Year: 2024 Accepted: 2025-03-31
Auditor: Forvis Mazars LLP

Organization Exclusion Status:

Findings

ID Ref Severity Repeat Requirement
547937 2024-002 Significant Deficiency - L
547938 2024-002 Significant Deficiency - L
547939 2024-002 Significant Deficiency - L
547940 2024-003 Significant Deficiency - N
547941 2024-003 Significant Deficiency - N
547942 2024-003 Significant Deficiency - N
1124379 2024-002 Significant Deficiency - L
1124380 2024-002 Significant Deficiency - L
1124381 2024-002 Significant Deficiency - L
1124382 2024-003 Significant Deficiency - N
1124383 2024-003 Significant Deficiency - N
1124384 2024-003 Significant Deficiency - N

Programs

ALN Program Spent Major Findings
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $701,678 Yes 2
93.493 Congressional Directives $322,398 - 0
93.965 Coal Miners Respiratory Impairment Treatment Clinics and Services $223,000 - 0
93.870 Maternal, Infant and Early Childhood Home Visiting Grant $212,500 - 0
93.527 Grants for New and Expanded Services Under the Health Center Program $169,822 Yes 2
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $97,500 - 0
93.994 Maternal and Child Health Services Block Grant to the States $86,000 - 0
93.800 Organized Approaches to Increase Colorectal Cancer Screening $43,087 - 0
93.859 Biomedical Research and Research Training $40,000 - 0
93.590 Community-Based Child Abuse Prevention Grants $2,006 - 0

Contacts

Name Title Type
YA54TMKN58P5 Michele Sarrett Auditee
3044694783 Justin Kensinger Auditor
No contacts on file

Notes to SEFA

Title: Note 1: Basis of Presentation Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule, if any, represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: New River Health Association, Inc. has elected not to use the 10 percent de minimis indirect cost rate allowed under the Uniform Guidance. The accompanying schedule of expenditures of federal awards (the “Schedule”) includes the federal award activity of New River Health Association, Inc. under programs of the federal government for the year ended June 30, 2024. The information in this schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Because the Schedule presents only a selected portion of the operations of New River Health Association, Inc., it is not intended to and does not present the financial position, results of operations, changes in net assets, or cash flows of New River Health Association, Inc.
Title: Note 4: Federal Loan Programs Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule, if any, represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: New River Health Association, Inc. has elected not to use the 10 percent de minimis indirect cost rate allowed under the Uniform Guidance. New River Health Association, Inc. did not have any federal loan programs during the year ended June 30, 2024.

Finding Details

Finding 2024-002
Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-002
Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-002
Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003
Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003
Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003
Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-002
Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-002
Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-002
Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003
Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003
Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Finding 2024-003
Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025