Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance
Criteria or specific requirement: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay (42 USC 254(k)(3)(G); 42 CFR sections 51c.303(f), and (g); and 42 CFR sections 56.303(f), and (g)).
Condition: The Organization did not maintain documentation to show that patients had been evaluated for eligibility under its sliding fee scale policy and did not apply sliding fee adjustments consistent with the sliding fee scale assigned.
Questioned costs: None.
Context:
• Nine (9) of sixty (60) encounters did not have family size and income documented within the billing system in order to assess sliding fee discount eligibility. Each of these encounters occurred prior to December 31, 2023.
• Five (5) of sixty (60) encounters did not have family size and income documentation updated within a year of the patient visit date. Three (3) of these encounters occurred prior to December 31, 2023 and two (2) occurred subsequent to December 31, 2023.
• Thirteen (13) of sixty (60) encounters received a sliding fee adjustment which was incorrect based on the sliding fee scale assigned. Seven (7) of these occurred prior to December 31, 2023 and six (6) occurred subsequent to December 31, 2023.
Cause: This matter was identified during a prior audit and required the Organization to make an update to the electronic medical records software and process for obtaining the necessary sliding fee information. The Organization started its corrective action during fiscal year 2024 upon becoming aware of the matter. As a result of when this matter was first identified, corrective action was not able to occur prior to the start of the fiscal year ended June 30, 2024.
Effect: Patients may not be assessed a correct sliding fee discount according to the Organization's sliding fee scale and their ability to pay.
Repeat Finding: Yes, prior year finding 2023-002.
Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies.
Views of responsible officials: There is no disagreement with this finding.
Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Material Weakness in Internal Control over Compliance and Immaterial Noncompliance
Criteria or specific requirement: Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; and support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award (2 CFR 200.430(i)(1)).
Condition: Payroll costs charged to federal grants were either missing documentation related to time and effort or were allocated to grants in a manner inconsistent with the time and effort documentation provided.
Questioned costs: $7,444
Context: Six (6) of forty (40) allowable cost transactions selected for testing were related to payroll costs and were missing time and effort documentation. Eight (8) of forty (40) allowable cost transactions selected for testing were related to payroll costs which were allocated to the grant in a manner inconsistent with the time and effort documentation provided. Two (2) of forty (40) allowable cost transactions selected for testing were related to payroll and contained a difference between the hours worked per the timesheet and hours paid per the payroll register.
Cause: Unknown
Effect: Grants may be allocated costs in a manner which is inconsistent with the actual level of effort associated with the underlying employee.
Repeat Finding: No.
Recommendation: Management should reenforce the requirement to retain time and effort documentation for all employees that are allocated to multiple grants and implement a review process whereby the allocation percentages used are compared to the employee attestations provided.
Views of responsible officials: There is no disagreement with this finding.
Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Significant Deficiency in Internal Control over Compliance
Criteria or specific requirement: 2 CFR section 200.320 outlines the acceptable methods of procurement. Purchases below the simplified acquisition threshold, but above the micro-purchase threshold, require that price or rate quotations be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. Noncompetitive procurement can be used in certain circumstances however the non-Federal entity is to maintain appropriate supporting documentation justifying the use of sole source procurement consistent with 2 CFR 200.320(c).
Condition: The organization did not maintain appropriate documentation to support the procurement method utilized for a contract selected for testing.
Questioned costs: None
Context: One (1) of five (5) procurement transactions selected for testing.
Cause: The Organization did not create and maintain appropriate documentation to support the method of procurement utilized, including the consideration of an adequate number of qualified sources.
Effect: Possible noncompliance with 2 CFR section 200.320(c)(1) - (3)
Repeat Finding: No.
Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list.
Views of responsible officials: There is no disagreement with this finding.
Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or specific requirement: 2 CFR 200.305(b)(1) requires that recipients of federal funds maintain both written procedures that minimize the time elapsing between the transfer of funds from the Federal agency and the disbursement of funds by the recipient, and financial management systems that meet the standards for fund control and accountability. Furthermore, 2 CFR 200.303 indicates the non-Federal entity must: (a) Establish, document and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: The Organization did not maintain timely documentation to support an independent review and approval of the drawdowns prior the drawdown occurring.
Questioned costs: None
Context: This condition occurred in two (2) of six (6) transactions selected for testing.
Cause: Turnover in key positions within the finance department.
Effect: Drawdowns may occur for the incorrect amount, for the wrong period and for costs that may not have been incurred as of yet.
Repeat Finding: No.
Recommendation: We recommend management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented with supporting documentation retained for the revised internal control.
Views of responsible officials: There is no disagreement with this finding.
Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance
Criteria or specific requirement: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay (42 USC 254(k)(3)(G); 42 CFR sections 51c.303(f), and (g); and 42 CFR sections 56.303(f), and (g)).
Condition: The Organization did not maintain documentation to show that patients had been evaluated for eligibility under its sliding fee scale policy and did not apply sliding fee adjustments consistent with the sliding fee scale assigned.
Questioned costs: None.
Context:
• Nine (9) of sixty (60) encounters did not have family size and income documented within the billing system in order to assess sliding fee discount eligibility. Each of these encounters occurred prior to December 31, 2023.
• Five (5) of sixty (60) encounters did not have family size and income documentation updated within a year of the patient visit date. Three (3) of these encounters occurred prior to December 31, 2023 and two (2) occurred subsequent to December 31, 2023.
• Thirteen (13) of sixty (60) encounters received a sliding fee adjustment which was incorrect based on the sliding fee scale assigned. Seven (7) of these occurred prior to December 31, 2023 and six (6) occurred subsequent to December 31, 2023.
Cause: This matter was identified during a prior audit and required the Organization to make an update to the electronic medical records software and process for obtaining the necessary sliding fee information. The Organization started its corrective action during fiscal year 2024 upon becoming aware of the matter. As a result of when this matter was first identified, corrective action was not able to occur prior to the start of the fiscal year ended June 30, 2024.
Effect: Patients may not be assessed a correct sliding fee discount according to the Organization's sliding fee scale and their ability to pay.
Repeat Finding: Yes, prior year finding 2023-002.
Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies.
Views of responsible officials: There is no disagreement with this finding.
Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Material Weakness in Internal Control over Compliance and Immaterial Noncompliance
Criteria or specific requirement: Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; and support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award (2 CFR 200.430(i)(1)).
Condition: Payroll costs charged to federal grants were either missing documentation related to time and effort or were allocated to grants in a manner inconsistent with the time and effort documentation provided.
Questioned costs: $7,444
Context: Six (6) of forty (40) allowable cost transactions selected for testing were related to payroll costs and were missing time and effort documentation. Eight (8) of forty (40) allowable cost transactions selected for testing were related to payroll costs which were allocated to the grant in a manner inconsistent with the time and effort documentation provided. Two (2) of forty (40) allowable cost transactions selected for testing were related to payroll and contained a difference between the hours worked per the timesheet and hours paid per the payroll register.
Cause: Unknown
Effect: Grants may be allocated costs in a manner which is inconsistent with the actual level of effort associated with the underlying employee.
Repeat Finding: No.
Recommendation: Management should reenforce the requirement to retain time and effort documentation for all employees that are allocated to multiple grants and implement a review process whereby the allocation percentages used are compared to the employee attestations provided.
Views of responsible officials: There is no disagreement with this finding.
Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Significant Deficiency in Internal Control over Compliance
Criteria or specific requirement: 2 CFR section 200.320 outlines the acceptable methods of procurement. Purchases below the simplified acquisition threshold, but above the micro-purchase threshold, require that price or rate quotations be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. Noncompetitive procurement can be used in certain circumstances however the non-Federal entity is to maintain appropriate supporting documentation justifying the use of sole source procurement consistent with 2 CFR 200.320(c).
Condition: The organization did not maintain appropriate documentation to support the procurement method utilized for a contract selected for testing.
Questioned costs: None
Context: One (1) of five (5) procurement transactions selected for testing.
Cause: The Organization did not create and maintain appropriate documentation to support the method of procurement utilized, including the consideration of an adequate number of qualified sources.
Effect: Possible noncompliance with 2 CFR section 200.320(c)(1) - (3)
Repeat Finding: No.
Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list.
Views of responsible officials: There is no disagreement with this finding.
Federal Agency: U.S. Department of Health and Human Services
Federal Program Title: Health Center Program Cluster
Assistance Listing Numbers: 93.224 and 93.527
Federal Award Identification Number and Year: H80CS00109-22; H80CS00109-23
Award Period: May 1, 2023 – April 30, 2024; May 1, 2024 – April 30, 2025
Type of Finding: Material Weakness in Internal Control over Compliance
Criteria or specific requirement: 2 CFR 200.305(b)(1) requires that recipients of federal funds maintain both written procedures that minimize the time elapsing between the transfer of funds from the Federal agency and the disbursement of funds by the recipient, and financial management systems that meet the standards for fund control and accountability. Furthermore, 2 CFR 200.303 indicates the non-Federal entity must: (a) Establish, document and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: The Organization did not maintain timely documentation to support an independent review and approval of the drawdowns prior the drawdown occurring.
Questioned costs: None
Context: This condition occurred in two (2) of six (6) transactions selected for testing.
Cause: Turnover in key positions within the finance department.
Effect: Drawdowns may occur for the incorrect amount, for the wrong period and for costs that may not have been incurred as of yet.
Repeat Finding: No.
Recommendation: We recommend management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented with supporting documentation retained for the revised internal control.
Views of responsible officials: There is no disagreement with this finding.