Audit 359871

Finding Number: 2024 001 Finding Type: Significant Deficiency in Internal Controls Over Compliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Awards: 2 H80CS04210 19 00 from May 1, 2023 through April 30, 2024 and 5 H80CS04210 29 00 from May 1, 2024 through April 30, 2025 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordance with their policy, the Organization will monitor the accuracy of the discounts provided to patients by a monthly random audit of 15 visits where a sliding fee discount adjustment was received. Condition: The Organization did not perform monitoring activities as outlined above from July 2024 through December 2024 as required by the Organization's sliding fee discount policy. Cause: The Organization was unable to complete the task as expected due to an exceptionally high workload during this period. They were managing multiple priorities, which required their immediate attention, and as a result, were not able to allocate the necessary time to this particular responsibility. Effect: It is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program and these errors may not be detected and corrected in a timely manner. Questioned Costs: None Repeat Finding: No Recommendation: To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 2. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences in order to maintain continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will implement the recommendations above and maintain consistency with their internal monitoring procedures moving forward.

Finding Number: 2024 001 Finding Type: Significant Deficiency in Internal Controls Over Compliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Awards: 2 H80CS04210 19 00 from May 1, 2023 through April 30, 2024 and 5 H80CS04210 29 00 from May 1, 2024 through April 30, 2025 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordance with their policy, the Organization will monitor the accuracy of the discounts provided to patients by a monthly random audit of 15 visits where a sliding fee discount adjustment was received. Condition: The Organization did not perform monitoring activities as outlined above from July 2024 through December 2024 as required by the Organization's sliding fee discount policy. Cause: The Organization was unable to complete the task as expected due to an exceptionally high workload during this period. They were managing multiple priorities, which required their immediate attention, and as a result, were not able to allocate the necessary time to this particular responsibility. Effect: It is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program and these errors may not be detected and corrected in a timely manner. Questioned Costs: None Repeat Finding: No Recommendation: To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 2. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences in order to maintain continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will implement the recommendations above and maintain consistency with their internal monitoring procedures moving forward.

Finding Number: 2024 001 Finding Type: Significant Deficiency in Internal Controls Over Compliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Awards: 2 H80CS04210 19 00 from May 1, 2023 through April 30, 2024 and 5 H80CS04210 29 00 from May 1, 2024 through April 30, 2025 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordance with their policy, the Organization will monitor the accuracy of the discounts provided to patients by a monthly random audit of 15 visits where a sliding fee discount adjustment was received. Condition: The Organization did not perform monitoring activities as outlined above from July 2024 through December 2024 as required by the Organization's sliding fee discount policy. Cause: The Organization was unable to complete the task as expected due to an exceptionally high workload during this period. They were managing multiple priorities, which required their immediate attention, and as a result, were not able to allocate the necessary time to this particular responsibility. Effect: It is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program and these errors may not be detected and corrected in a timely manner. Questioned Costs: None Repeat Finding: No Recommendation: To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 2. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences in order to maintain continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will implement the recommendations above and maintain consistency with their internal monitoring procedures moving forward.

Finding Number: 2024 001 Finding Type: Significant Deficiency in Internal Controls Over Compliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Awards: 2 H80CS04210 19 00 from May 1, 2023 through April 30, 2024 and 5 H80CS04210 29 00 from May 1, 2024 through April 30, 2025 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordance with their policy, the Organization will monitor the accuracy of the discounts provided to patients by a monthly random audit of 15 visits where a sliding fee discount adjustment was received. Condition: The Organization did not perform monitoring activities as outlined above from July 2024 through December 2024 as required by the Organization's sliding fee discount policy. Cause: The Organization was unable to complete the task as expected due to an exceptionally high workload during this period. They were managing multiple priorities, which required their immediate attention, and as a result, were not able to allocate the necessary time to this particular responsibility. Effect: It is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program and these errors may not be detected and corrected in a timely manner. Questioned Costs: None Repeat Finding: No Recommendation: To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 2. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences in order to maintain continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will implement the recommendations above and maintain consistency with their internal monitoring procedures moving forward.