Audit 363352

FY End
2023-09-30
Total Expended
$10.73M
Findings
24
Programs
20
Year: 2023 Accepted: 2025-07-30
Auditor: McConnell Jones

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
572213 2023-002 Material Weakness - N
572214 2023-002 Material Weakness - N
572215 2023-002 Material Weakness - N
572216 2023-002 Material Weakness - N
572217 2023-003 Significant Deficiency - L
572218 2023-003 Significant Deficiency - L
572219 2023-003 Significant Deficiency - L
572220 2023-003 Significant Deficiency - L
572221 2023-004 Significant Deficiency - C
572222 2023-004 Significant Deficiency - C
572223 2023-004 Significant Deficiency - C
572224 2023-004 Significant Deficiency - C
1148655 2023-002 Material Weakness - N
1148656 2023-002 Material Weakness - N
1148657 2023-002 Material Weakness - N
1148658 2023-002 Material Weakness - N
1148659 2023-003 Significant Deficiency - L
1148660 2023-003 Significant Deficiency - L
1148661 2023-003 Significant Deficiency - L
1148662 2023-003 Significant Deficiency - L
1148663 2023-004 Significant Deficiency - C
1148664 2023-004 Significant Deficiency - C
1148665 2023-004 Significant Deficiency - C
1148666 2023-004 Significant Deficiency - C

Programs

ALN Program Spent Major Findings
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $2.42M Yes 3
10.557 Special Supplemental Nutrition Program for Women, Infants, and Children $1.08M Yes 0
93.268 Immunization Cooperative Agreements $802,973 Yes 0
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $675,715 - 0
21.027 Coronavirus State and Local Fiscal Recovery Funds $376,864 - 0
93.977 Preventive Health Services_sexually Transmitted Diseases Control Grants $254,582 - 0
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $242,087 - 0
66.472 Beach Monitoring and Notification Program Implementation Grants $132,301 - 0
93.991 Preventive Health and Health Services Block Grant $117,042 - 0
93.940 Hiv Prevention Activities_health Department Based $108,178 - 0
97.091 Homeland Security Biowatch Program $107,586 - 0
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $102,260 - 0
93.994 Maternal and Child Health Services Block Grant to the States $73,478 - 0
93.008 Medical Reserve Corps Small Grant Program $48,679 - 0
66.605 Performance Partnership Grants $47,692 - 0
93.116 Project Grants and Cooperative Agreements for Tuberculosis Control Programs $43,902 - 0
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $25,257 - 0
93.069 Public Health Emergency Preparedness $17,050 - 0
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $5,118 Yes 3
93.967 Cdc's Collaboration with Academia to Strengthen Public Health $3,775 - 0

Contacts

Name Title Type
SK8BQZM1Z5P5 Ruth E Cable Auditee
4099382460 Chuck Kozlik Auditor
No contacts on file

Notes to SEFA

Title: Note 1 - The Organization Accounting Policies: In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. De Minimis Rate Used: N Rate Explanation: N/A The Galveston County Health District (the “District”) receives federal and state grants to provide community health and related services to low-income families throughout the Galveston County, pursuant to the public health administration component of the District’s charter.
Title: Note 2 - Basis of Presentation Accounting Policies: In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. De Minimis Rate Used: N Rate Explanation: N/A The accompanying schedules of expenditures of federal and state awards (the “Schedules”) include the financial award activities of the District under programs of the federal government and of the State of Texas for the fiscal year ended September 30, 2023. The information in the Schedules is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the “Uniform Guidance”) and the State of Texas Single Audit Circular. Because the Schedule presents only a selected portions of the District’s operations, it is not intended to and does not present the net position or changes in net position of the District.
Title: Note 3 - Summary of Significant Accounting Policies Accounting Policies: In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. De Minimis Rate Used: N Rate Explanation: N/A In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. Federal and state grant funds are considered to be earned to the extent of qualifying expenditures made under the provisions of the grants. When such funds are advanced to the District, they are recorded as deferred revenues until earned. Otherwise, federal and state grant funds are received on a reimbursement basis from the respective federal and state program agencies or pass-through entities.
Title: Note 4 – Indirect Cost Rate Accounting Policies: In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. De Minimis Rate Used: N Rate Explanation: N/A The District did not elect to use the 10% de minimis indirect cost rate allowed under the Uniform Guidance.
Title: Note 5 – Program Income Accounting Policies: In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. De Minimis Rate Used: N Rate Explanation: N/A The District did not generate program income. Accordingly, no program income was used to reduce the amount of federal or state funds expended in providing the programs. Similarly, any program expenditures funded in cash or kind to meet the District’s matching contributions, where applicable, to grant budgets have not been included in the amounts reported on the Schedules.
Title: Note 6 - Relationship of the Schedules to the Financial Reports Submitted to Grant Awarding Agencies Accounting Policies: In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. De Minimis Rate Used: N Rate Explanation: N/A Expenditures included on the Schedules may differ from amounts reflected in the financial reports submitted to grant awarding agencies and pass-through entities because of the following reasons: 1. Expenses accrued at the end of the District’s fiscal year may not have been included in the financial reports submitted to grant awarding agencies until after fiscal year-end. 2. Program matching costs that are reported, where applicable, in the financial reports submitted to grant awarding agencies are not included in the amounts reported on the Schedules; and 3. Differences may exist between grant periods and the District’s accounting period.
Title: Note 7 - Contingencies Accounting Policies: In accordance with U.S. generally accepted accounting principles, the District accounts for all awards under federal and state programs on an accrual basis of accounting. Accordingly, expenditures reported on the Schedules are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance and the State of Texas Uniform Grant Management Standards, wherein certain types of expenditures are not allowable or are limited as to reimbursement by the federal and/or state funding agencies. De Minimis Rate Used: N Rate Explanation: N/A Federal and state grants require the fulfillment of certain conditions set forth in grant agreements, and may be regularly monitored and reviewed by grantors, both during and after the programs. Failure to satisfy the requirements of contract agreements could result in disallowed costs and return of funds to grantors. Management believes that the District is in substantial compliance with grant provisions and requirements and that disallowed costs, if any, will not be significant to affect the amounts and disclosures in the Schedules or the District’s basic financial statements.

Finding Details

Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.
Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: The District’s internal control structure should ensure that patients whom have filled out a sliding scale fee application were charged the appropriate rate. Condition: During the audit, it was identified one patient out of twenty-five tested was charged an inappropriate amount when compared to the sliding fee scale application filled out. The patient was accurately determined to be a full discount eligible, self-pay patient. While reviewing the invoice billed to the patient, it was determined that all charge codes except the coronavirus lab test fee were fully discounted appropriately. After noting that one incident, an additional seven patients who were billed with the coronavirus charge code were reviewed. All of the seven patients reviewed, of varying discount eligibility, were noted to have been fully charged for the coronavirus lab fee. Cause: The coronavirus lab test code was manually overwritten to exempt the sliding fee scale eligibility determination due to a previous grant covering the fee. The grant that covered this expense for self pay patients had lapsed and the manual override was not removed. Effect: Self pay patients of varying discount eligibility were fully charged for the coronavirus lab test. Recommendation: We recommend that the District review invoices for self-pay patients to ensure they are being accurately billed. We also recommend that manual overrides are reviewed periodically. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Annually, the District is required to report patient characteristics along with financial data within the Uniform Data Systems report and submit it to the Health Resources & Services Administration online. The District’s internal control structure should ensure that their Uniform Data System annual report is complete and accurate. Condition: During the audit, it was identified that four of seven key line items reviewed within the Uniform Data System report for 2023 were unable to be substantiated. The first key line item reviewed revolved around patient numbers and data received supported 11,584 patients while 11,575 patients were reported. For second the key line item reviewed, regarding total physician clinic and virtual visits, data reports provided supported 8,330 physician visits while 10,893 physician visits were noted as being reported within the Uniform Data System report. The third key line item reviewed was total accrued costs before donations and after allocation of overhead. Data supplied showed $14,466,183 which was $39,967 less than what was reported on the Uniform Data System report. The final key line reviewed with exception was regarding total accrued medical staff and other medical cost after allocation of overhead excluding lab and x-ray cost with a total cost within the Uniform Data System reported as $7,393,886, for this key item, no support was supplied. Cause: While the financial system has the data to back up most of the initial figures reported, comments left by Health Resources & Services Administration reviewers required adjustment to some of the key line items. Effect: The final Uniform Data System report has non-financial and financial data that cannot be substantiated at the amount reported as the adjustments and reasoning for those adjustments were not reconciled. Recommendation: We recommend that the District create reports that capture the data and is reconciled to the final Uniform Data System report filed. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District was already in the midst of creating Uniform Data System reports within their financial reporting software in order to be able to reconcile to final reports uploaded.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.
Criteria: Monthly, the District is required to request funds in the form of a draw down from Health Resources & Services Administration online. The District’s internal control structure should ensure that draw down support is complete, accurate, and made available in a timely and orderly manner. Condition: During the audit, it was identified that two of four draw downs were not supported completely and consistently. The February 2023 draw down support was completely unsubstantiated for the $366,785 requested and received. The November 2022 draw down was substantiated in support; however, approval for the draw down was not noted as being received. Cause: Previous leadership processes maintained a majority of their draw down support in paper files that were disorganized which created a difficulty in re-producing for substantiation. Effect: The draw down support for November 2022 and February 2023 was not complete. Recommendation: We recommend that the District retain all support in regards to draw downs and create a better filing system. Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s new leadership is already in the process of improving the document support, retention, and filing system in order to alleviate missing documents.