Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025
Criteria:
The auditee must prepare the Schedule of Expenditures of Federal Awards (SEFA) for the period under audit in accordance with the Uniform Guidance Sections 2 CFR 200.302(b) and 2 CFR 200.510(b).
Condition:
During our audit of the SEFA submitted by the Clinic, we noted that the Clinic inadvertently included nonfederal grants in the SEFA. Further, the Clinic inaccurately included out-of-performance period expenses in its SEFA due to inaccurate identification of the grant period during the SEFA preparation. The Clinic corrected the SEFA after the errors were brought to their attention.
Cause:
Wilmington was short-staffed and dealt with time constraints in the preparation and review of the SEFA.
Effect:
Inaccurate SEFA can lead to improper risk assessment and incorrect identification of major federal programs subject to audit. Revisions of the SEFA were necessary to ensure the completeness and accuracy of the federal expenditures reported.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic revisit its internal control processes over the preparation and review of the SEFA in conjunction with its other federal reporting requirements to ensure that the SEFA and all federal reports for internal and external purposes are accurate and complete.
Views of responsible officials and planned corrective actions:
The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO).
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Services as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will seek professional consultation and guidance to create a work schedule compliant with reporting deadlines and submissions and provide oversight to ensure those deadlines are met.
Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors
Date of implementation: July 1, 2025
Criteria:
As per the Reporting Guidelines issued by the U.S. Department of Health and Human Services for the Health Center Program Cluster grants, the annual Federal Financial Reports (FFR) deadlines are as follows:
Budget Period ends August, September October: FFR due January 30
Budget Period ends November, December, January: FFR due April 30
Budget Period ends February, March, April: FFR due July 30
Budget Period ends May, June, July: FFR due October 30
Condition:
The Clinic was unable to meet the deadlines for the following reports:
Program Identification Number Required Report Frequency Report Period End Date Due Date Date Submitted Lag in Days
H80CS24202-12-02 FFR Annual May 31, 2024 October 30, 2024 November 14, 2024 15
H8FCS41205‐01‐03 FFR Annual March 31, 2024 July 30, 2024 July 31, 2024 1
H8GCS47840‐01‐02 FFR Annual December 31, 2023 April 30, 2024 July 31, 2024 92
Cause:
The Clinic had a significant change in leadership from 2023 to 2024.
Effect:
Failure to comply with the above-mentioned reporting requirements may result in the deferral or cancellation of federal funds or additional restrictions on future funding decisions.
Questioned Costs:
None.
Recommendation:
We recommend that the Clinic strictly follow and monitor the deadline for reporting submissions set forth by the U.S. Department of Health and Human Resources as part of its compliance requirements.
Views of responsible officials and planned corrective actions:
The Clinic will be hiring a new CFO who will be monitoring all reporting deadlines and submission. The new CFO will create a work schedule and ensure the team reports in a timely manner.
Criteria:
Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines.
Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project.
Condition:
The Clinic determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following:
• Three patients were charged with the incorrect sliding fee amount, which resulted in the Clinic overcharging the patients by a total of $48.
• One patient had no sliding fee application form on file effective at the date of service. Due to an unsupported sliding fee discount, we were unable to determine if the patient was eligible for the sliding fee and should have been charged the full amount of $41.99, resulting to a potential undercharge.
Cause:
The Clinic believes the cause was a shift in front office staff that collects, retains, and applies sliding fees.
Effect:
The determination of patient fees is not consistent with the sliding fee schedule.
Questioned Costs:
$6.01 in net overcharges for sliding fee patients sampled.
Recommendation:
We recommend that the Clinic’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Clinic should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Clinic’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of responsible officials and planned corrective actions:
The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager.
Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager
Date of implementation: June 1, 2025