Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-002 Reporting
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Reporting – Federal Financial Report and Uniform Data System
Condition: Federal Financial Reports (FFR) submitted to the Department of Health and Human Services (DHHS) during the fiscal year ended December 31, 2024 were not submitted timely in accordance with the terms of their related grants. There were 10 FFR filings that were submitted late. There were 4 FFR filings that were submitted with incorrect amounts for the federal share of expenditures. In addition, the Uniform Data System (UDS) report submitted to DHHS for the year ended December 31, 2024, contained incorrect data for total federal grant revenue. The federal grant revenue was understated on Table 9E of the UDS report by approximately $8.2 million.
Cause: The Organization did not submit timely or accurate FFR filings and did not correctly report federal grant revenue in the UDS.
Effect: FFR filings were late for 10 filings and federal share of expenditures were not correctly reported in 4 FFR filings. Also, the federal grant revenue was understated in the UDS.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that a system is developed in which the filing deadlines for FFR filings are monitored for timely submissions. In addition, it is recommended that the FFR filings and the UDS are reviewed by a person other than the preparer of the report prior to submission to ensure accurate reporting.
Views of Responsible Officials: Management concurs. Procedures will be established to ensure that FFR filings and UDS reports are filed accurately and in a timely manner.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-003 Cash Management – Federal Grants
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Cash Management, 45 CFR 75.305
Condition: The Organization failed to reconcile expenditures to federal grant draws prior to transferring the federal funds to the Organization’s bank account. No grant draws exceeded the cash needs for grant related expenditures. However, failure to reconcile expenditures to federal grant draws could result in grant draws in excess of expenditures.
Cause: The Organization failed to reconcile expenditures prior to drawing federal grant funds.
Effect: Without proper controls, including reconciliations of expenditures prior to drawing federal grant funds, advance draws could occur.
Questioned Costs: None reported.
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that, before the Organization makes a draw of federal funds, a report of year-to-date program expenditures paid as well as year-to-date funds drawn be reviewed to ensure that no unauthorized federal funds are drawn down in excess of expenditures.
Views of Responsible Officials: Management concurs. Management will reconcile all expenditures prior to making the federal grant draws to ensure that advance draws of federal funds do not occur.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-004 Procurement, Suspension and Debarment
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213
Condition: The Organization did not follow its policy governing procurement requirements for the purchase of goods or services.
Cause: The Organization did not obtain quotes or bids for certain expenditures as required by the Organization’s procurement policy.
Effect: Purchases were made that did not adhere to the Organization’s procurement policy.
Questioned Costs: None reported
Context/Sampling: The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that procurement controls be implemented to ensure that quotes or bids are obtained as required by the Organization’s procurement policy.
Views of Responsible Officials: Management concurs. Procedures will be updated, and employees will be trained to ensure compliance with the procurement requirements.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025
Finding: 2024-005 Sliding Fee Discounts
Federal Programs: Department of Health and Human Services
Health Center Program Cluster
Assistance Listing No. - 93.224 and 93.527
Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303
Condition: Health centers that receive funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not obtain and properly document all necessary elements required by the Organization’s policy and that incorrect sliding fee discounts were applied to certain patient accounts.
Cause: There were deficiencies in internal controls over the Organization’s sliding fee program. For certain patient accounts that were tested as part of the audit, the Organization was unable to substantiate that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale and that incorrect sliding fee discounts were applied to certain patient accounts.
Effect: Proper documentation was unavailable to substantiate that discounts were properly applied to patient accounts, and incorrect discounts were applied to certain patient accounts.
Questioned Costs: None
Context/Sampling: For 6 of 48 patients selected for testing, incorrect discounts were provided. Four patients selected received an incorrect discount, and two patients received a discount who did not qualify for a discount. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.
Repeat Finding from Prior Year: Yes
Recommendation: It is recommended that employees are properly trained to document and apply the sliding fee discounts in accordance with the Organization’s sliding fee policy. It is also recommended that sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above.
Contact Person: Dondre Wilson, CFO
Anticipated Date of Completion: July 31, 2025