Audit 354557

FY End
2024-12-31
Total Expended
$2.68M
Findings
16
Programs
9
Year: 2024 Accepted: 2025-04-24

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
555899 2024-001 Significant Deficiency Yes N
555900 2024-001 Significant Deficiency Yes N
555901 2024-001 Significant Deficiency Yes N
555902 2024-001 Significant Deficiency Yes N
555903 2024-002 Significant Deficiency - I
555904 2024-002 Significant Deficiency - I
555905 2024-002 Significant Deficiency - I
555906 2024-002 Significant Deficiency - I
1132341 2024-001 Significant Deficiency Yes N
1132342 2024-001 Significant Deficiency Yes N
1132343 2024-001 Significant Deficiency Yes N
1132344 2024-001 Significant Deficiency Yes N
1132345 2024-002 Significant Deficiency - I
1132346 2024-002 Significant Deficiency - I
1132347 2024-002 Significant Deficiency - I
1132348 2024-002 Significant Deficiency - I

Contacts

Name Title Type
CH8MR5ENJKZ1 Dan Becker Auditee
9702001625 James Mann Auditor
No contacts on file

Notes to SEFA

Accounting Policies: This note is included to meet the requirements of 2 CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requirement that the schedule of expenditures of federal awards (the Schedule) include notes that describe the significant accounting policies used in preparing the Schedule. The accompanying schedule is prepared on the accrual basis of accounting and includes the federal award activity of the Organization under programs of the federal government for the year ended December 31, 2024. The information in this Schedule is presented in accordance with the requirements of the Uniform Guidance. The Organization has not elected to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. Because the Schedule presents only a selected portion of the operations of the Organization, it is not intended to and does not present the financial position, changes in net assets, or cash flows of the Organization. De Minimis Rate Used: N Rate Explanation: The Organization has not elected to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance.

Finding Details

Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit where a sliding fee application could not be found to support the slide provided. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the sliding fee application was not saved in the patients file. Recommendation We recommend the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Views of Responsible Officials Management agrees that this was a clerical error and an isolated incident. To improve the process and minimize errors, eligibility applications will now be processed at the Grand Junction, Colorado office by a different eligibility staff. This team will enter applications into the electronic medical record system and maintain either paper or digital copies for one year to ensure no applications are lost. This new procedure will provide an additional safeguard in the application process.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.
Criteria or Specific Requirement 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context During our testing over suspension and debarment, we noted one instance in which the Organization was unable to locate documentation that a suspension and debarment check was performed prior to entering into a transaction with a vendor. Effect Noncompliance results in possible federal funds provided to ineligible vendors. Questioned Costs None identified. Cause The Organization does not have internal controls in place to ensure compliance with federal regulations or the terms and conditions of the federal award. Recommendation We recommend the Organization implement a process to ensure that procurement and suspension and debarment documentation is retained. Views of Responsible Officials The Organization has a program called Compliatric that the Organization can load all of its vendors into and it will check on a monthly basis the registries for Debarment and Exclusions from Federal Programs with a log to track this screening. The Organization has changed the accounts payable process to include adding all new vendors to the Compliatric list for screening compliance. The Organization feels this will ensure ongoing compliance of all vendors on a monthly basis going forward. Any matches will require either the Risk and Compliance Manager or the CFO to review and validate the match or identify that the match is an error. If validation is found to be correct all purchasing and use of that vendor will be terminated going forward.