Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing No. 93.498
U.S. Department of Health and Human Services
COVID-19- Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution
Criteria or Specific Requirement – Reporting (45 CFR 75.342) and Activities Allowed/Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622, Pub. L. No. 116-260, Pub. L. No. 117-2)
Condition – Within the Provider Relief Fund Reporting Portal for Period 1, the Organization reported other Provider Relief Fund (PRF) expenses and lost revenues calculated using option i. The Organization did not maintain
adequate documentation to support some other PRF expenses were attributable to coronavirus, incurred following the accrual basis of accounting during the period of availability, and/or not eligible to be reimbursed by other sources. The Organization also did not calculate lost revenues following the accrual basis of accounting and other guidance issued by HHS.
Questioned costs – $1,566,926; Calculated as total expense charged to PRF for Period 1.
Context – The Period 1 PRF report was tested. The Organization allocated salaries and employee benefits to PRF for time associated with COVID-19 prevention activities; however, these salaries and benefits were not supported as incremental and necessary costs for the prevention, preparation and response to COVID-19 and a portion of these salaries and benefits were also reimbursed by other sources. The Organization calculated lost revenues of $668,478 based on patient service revenue information from the practice management system rather than lost revenues of $946,314 based on accrual basis financial records.
Effect –Based on the Period 1 PRF report filed, the Organization utilized PRF payments received on expenses and lost revenues that were not attributable to coronavirus, were reimbursed by other sources, and/or were not allowable in accordance with other guidance issued by HHS.
Cause – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution is a new program with complex and evolving regulations and compliance requirements. Internal controls were not in place to ensure the Organization correctly applied the guidance.
Identification as a repeat finding – Not a repeat finding.
Recommendation – Policies and procedures over allowable activities and federal grant reporting should be modified to ensure expenditures charged to grants are for activities allowed and federal grant reports are prepared using complete and accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Reporting – 45 CFR 75.342
Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information.
Questioned costs – None
Context – Two reports from those listed above were selected for testing. The sampling methodology used was not, was not intended to be, statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and two exceptions were noted related to the annual FFR.
Effect – 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. Turnover in key positions resulted in the Organization being unable to support two attributes selected for testing on the UDS report. Program income reported on the annual FFR was not reported at the correct amount nor on the proper lines.
Identification as a repeat finding – Repeat of 2020-004 finding
Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 2 H80CS04226-16-00
Program Year 2021
Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f).
Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy.
Questioned costs – None
Context – A sample of 40 patients were tested out of the total population of 39,665 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 6 were determined to include errors in the application of the sliding fee discount program and policy.
Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given.
Cause – The Organization did not comply with their sliding fee discount policy.
Identification as a repeat finding – Repeat finding of finding 2020-005
Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing No. 93.498
U.S. Department of Health and Human Services
COVID-19- Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution
Criteria or Specific Requirement – Reporting (45 CFR 75.342) and Activities Allowed/Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622, Pub. L. No. 116-260, Pub. L. No. 117-2)
Condition – Within the Provider Relief Fund Reporting Portal for Period 1, the Organization reported other Provider Relief Fund (PRF) expenses and lost revenues calculated using option i. The Organization did not maintain
adequate documentation to support some other PRF expenses were attributable to coronavirus, incurred following the accrual basis of accounting during the period of availability, and/or not eligible to be reimbursed by other sources. The Organization also did not calculate lost revenues following the accrual basis of accounting and other guidance issued by HHS.
Questioned costs – $1,566,926; Calculated as total expense charged to PRF for Period 1.
Context – The Period 1 PRF report was tested. The Organization allocated salaries and employee benefits to PRF for time associated with COVID-19 prevention activities; however, these salaries and benefits were not supported as incremental and necessary costs for the prevention, preparation and response to COVID-19 and a portion of these salaries and benefits were also reimbursed by other sources. The Organization calculated lost revenues of $668,478 based on patient service revenue information from the practice management system rather than lost revenues of $946,314 based on accrual basis financial records.
Effect –Based on the Period 1 PRF report filed, the Organization utilized PRF payments received on expenses and lost revenues that were not attributable to coronavirus, were reimbursed by other sources, and/or were not allowable in accordance with other guidance issued by HHS.
Cause – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution is a new program with complex and evolving regulations and compliance requirements. Internal controls were not in place to ensure the Organization correctly applied the guidance.
Identification as a repeat finding – Not a repeat finding.
Recommendation – Policies and procedures over allowable activities and federal grant reporting should be modified to ensure expenditures charged to grants are for activities allowed and federal grant reports are prepared using complete and accurate information.