Audit 364008

FY End
2024-12-31
Total Expended
$5.24M
Findings
12
Programs
3
Year: 2024 Accepted: 2025-08-10

Organization Exclusion Status:

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Contacts

Name Title Type
C5Z4PGUWE3A5 David Sansoterra Auditee
3307479551 Wes Ernst Auditor
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Notes to SEFA

Title: Federal Loan Programs Accounting Policies: Note 1: Basis of Presentation - The accompanying schedule of expenditures of federal awards (Schedule) includes the federal award activity of the Organization under programs of the federal government for the year ended December 31, 2024. The information in this Schedule 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 (Uniform Guidance). Because the Schedule presents only a selected portion of the operations of the Organization, it is not intended to and does not present the financial position, changes in net assets or cash flows of the Organization. Note 2: Summary of Significant Accounting Policies - Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule, if any, represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: The Organization has elected not to use the 10% de minimis indirect cost rate allowed under the Uniform Guidance. The Organization administered no federal loan programs for the year ended December 31, 2024.

Finding Details

Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must comply with federal reporting requirements. Condition – The Organization incorrectly reported a certain line item on the Uniform Data System (UDS) report filed. Within Table 9E of the UDS report, the amount reported within line 1q column A was inaccurate. Recommendation – We recommend management implement an additional layer of review of reports by an individual with knowledge of the reporting requirements. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action. Cause – There was a lack of detailed review of the amounts reported on the UDS. Effect or potential effect – Inaccurate filing of reports may result in the federal program not being properly monitored, thus resulting in potential noncompliance with program requirements. Questioned costs – None Context – 1 special report was required to be submitted during the year under audit (UDS), thus this was the only report selected for testing. On this report 10 line items were tested, and of those 10 items, 1 of the lines was inaccurately reported. Identification as a repeat finding – Not a repeat finding.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must prepare and apply a sliding fee discount schedule that incorporates the provisions of 42 CFR 51c.303e through 56.303g to ensure that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition – The audit of the major federal program identified errors in the application of sliding fee adjustments. Cause – The sliding fee calculation was improperly set up within the Electronic Health Record System. Effect or potential effect – Inaccurate application of sliding fee adjustments may result in potential noncompliance with program requirements. Questioned costs – Not applicable Context – Out of a population of 1,478 sliding fee adjustments, a sample of 25 adjustments were tested. Out of the 25 tested, 6 adjustments were incorrectly calculated based on the Organization’s approved sliding fee scales and the patient’s sliding fee application. A non-statistical sampling methodology was used to select the sample. Identification as a repeat finding – Is a repeat finding (see 2023-001) Recommendation – We recommend that the Organization perform a review of the calculation of the sliding fee adjustments within the Electronic Health Record system to ensure it is properly set up. Additionally, we recommend that a member of management with an understanding of the Organization’s billing and sliding fee policies regularly review a sample of sliding fee adjustments in comparison to the Organization’s sliding fee policy. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must comply with federal reporting requirements. Condition – The Organization incorrectly reported a certain line item on the Uniform Data System (UDS) report filed. Within Table 9E of the UDS report, the amount reported within line 1q column A was inaccurate. Recommendation – We recommend management implement an additional layer of review of reports by an individual with knowledge of the reporting requirements. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action. Cause – There was a lack of detailed review of the amounts reported on the UDS. Effect or potential effect – Inaccurate filing of reports may result in the federal program not being properly monitored, thus resulting in potential noncompliance with program requirements. Questioned costs – None Context – 1 special report was required to be submitted during the year under audit (UDS), thus this was the only report selected for testing. On this report 10 line items were tested, and of those 10 items, 1 of the lines was inaccurately reported. Identification as a repeat finding – Not a repeat finding.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must prepare and apply a sliding fee discount schedule that incorporates the provisions of 42 CFR 51c.303e through 56.303g to ensure that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition – The audit of the major federal program identified errors in the application of sliding fee adjustments. Cause – The sliding fee calculation was improperly set up within the Electronic Health Record System. Effect or potential effect – Inaccurate application of sliding fee adjustments may result in potential noncompliance with program requirements. Questioned costs – Not applicable Context – Out of a population of 1,478 sliding fee adjustments, a sample of 25 adjustments were tested. Out of the 25 tested, 6 adjustments were incorrectly calculated based on the Organization’s approved sliding fee scales and the patient’s sliding fee application. A non-statistical sampling methodology was used to select the sample. Identification as a repeat finding – Is a repeat finding (see 2023-001) Recommendation – We recommend that the Organization perform a review of the calculation of the sliding fee adjustments within the Electronic Health Record system to ensure it is properly set up. Additionally, we recommend that a member of management with an understanding of the Organization’s billing and sliding fee policies regularly review a sample of sliding fee adjustments in comparison to the Organization’s sliding fee policy. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must comply with federal reporting requirements. Condition – The Organization incorrectly reported a certain line item on the Uniform Data System (UDS) report filed. Within Table 9E of the UDS report, the amount reported within line 1q column A was inaccurate. Recommendation – We recommend management implement an additional layer of review of reports by an individual with knowledge of the reporting requirements. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action. Cause – There was a lack of detailed review of the amounts reported on the UDS. Effect or potential effect – Inaccurate filing of reports may result in the federal program not being properly monitored, thus resulting in potential noncompliance with program requirements. Questioned costs – None Context – 1 special report was required to be submitted during the year under audit (UDS), thus this was the only report selected for testing. On this report 10 line items were tested, and of those 10 items, 1 of the lines was inaccurately reported. Identification as a repeat finding – Not a repeat finding.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must prepare and apply a sliding fee discount schedule that incorporates the provisions of 42 CFR 51c.303e through 56.303g to ensure that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition – The audit of the major federal program identified errors in the application of sliding fee adjustments. Cause – The sliding fee calculation was improperly set up within the Electronic Health Record System. Effect or potential effect – Inaccurate application of sliding fee adjustments may result in potential noncompliance with program requirements. Questioned costs – Not applicable Context – Out of a population of 1,478 sliding fee adjustments, a sample of 25 adjustments were tested. Out of the 25 tested, 6 adjustments were incorrectly calculated based on the Organization’s approved sliding fee scales and the patient’s sliding fee application. A non-statistical sampling methodology was used to select the sample. Identification as a repeat finding – Is a repeat finding (see 2023-001) Recommendation – We recommend that the Organization perform a review of the calculation of the sliding fee adjustments within the Electronic Health Record system to ensure it is properly set up. Additionally, we recommend that a member of management with an understanding of the Organization’s billing and sliding fee policies regularly review a sample of sliding fee adjustments in comparison to the Organization’s sliding fee policy. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must comply with federal reporting requirements. Condition – The Organization incorrectly reported a certain line item on the Uniform Data System (UDS) report filed. Within Table 9E of the UDS report, the amount reported within line 1q column A was inaccurate. Recommendation – We recommend management implement an additional layer of review of reports by an individual with knowledge of the reporting requirements. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action. Cause – There was a lack of detailed review of the amounts reported on the UDS. Effect or potential effect – Inaccurate filing of reports may result in the federal program not being properly monitored, thus resulting in potential noncompliance with program requirements. Questioned costs – None Context – 1 special report was required to be submitted during the year under audit (UDS), thus this was the only report selected for testing. On this report 10 line items were tested, and of those 10 items, 1 of the lines was inaccurately reported. Identification as a repeat finding – Not a repeat finding.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must prepare and apply a sliding fee discount schedule that incorporates the provisions of 42 CFR 51c.303e through 56.303g to ensure that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition – The audit of the major federal program identified errors in the application of sliding fee adjustments. Cause – The sliding fee calculation was improperly set up within the Electronic Health Record System. Effect or potential effect – Inaccurate application of sliding fee adjustments may result in potential noncompliance with program requirements. Questioned costs – Not applicable Context – Out of a population of 1,478 sliding fee adjustments, a sample of 25 adjustments were tested. Out of the 25 tested, 6 adjustments were incorrectly calculated based on the Organization’s approved sliding fee scales and the patient’s sliding fee application. A non-statistical sampling methodology was used to select the sample. Identification as a repeat finding – Is a repeat finding (see 2023-001) Recommendation – We recommend that the Organization perform a review of the calculation of the sliding fee adjustments within the Electronic Health Record system to ensure it is properly set up. Additionally, we recommend that a member of management with an understanding of the Organization’s billing and sliding fee policies regularly review a sample of sliding fee adjustments in comparison to the Organization’s sliding fee policy. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must comply with federal reporting requirements. Condition – The Organization incorrectly reported a certain line item on the Uniform Data System (UDS) report filed. Within Table 9E of the UDS report, the amount reported within line 1q column A was inaccurate. Recommendation – We recommend management implement an additional layer of review of reports by an individual with knowledge of the reporting requirements. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action. Cause – There was a lack of detailed review of the amounts reported on the UDS. Effect or potential effect – Inaccurate filing of reports may result in the federal program not being properly monitored, thus resulting in potential noncompliance with program requirements. Questioned costs – None Context – 1 special report was required to be submitted during the year under audit (UDS), thus this was the only report selected for testing. On this report 10 line items were tested, and of those 10 items, 1 of the lines was inaccurately reported. Identification as a repeat finding – Not a repeat finding.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must prepare and apply a sliding fee discount schedule that incorporates the provisions of 42 CFR 51c.303e through 56.303g to ensure that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition – The audit of the major federal program identified errors in the application of sliding fee adjustments. Cause – The sliding fee calculation was improperly set up within the Electronic Health Record System. Effect or potential effect – Inaccurate application of sliding fee adjustments may result in potential noncompliance with program requirements. Questioned costs – Not applicable Context – Out of a population of 1,478 sliding fee adjustments, a sample of 25 adjustments were tested. Out of the 25 tested, 6 adjustments were incorrectly calculated based on the Organization’s approved sliding fee scales and the patient’s sliding fee application. A non-statistical sampling methodology was used to select the sample. Identification as a repeat finding – Is a repeat finding (see 2023-001) Recommendation – We recommend that the Organization perform a review of the calculation of the sliding fee adjustments within the Electronic Health Record system to ensure it is properly set up. Additionally, we recommend that a member of management with an understanding of the Organization’s billing and sliding fee policies regularly review a sample of sliding fee adjustments in comparison to the Organization’s sliding fee policy. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must comply with federal reporting requirements. Condition – The Organization incorrectly reported a certain line item on the Uniform Data System (UDS) report filed. Within Table 9E of the UDS report, the amount reported within line 1q column A was inaccurate. Recommendation – We recommend management implement an additional layer of review of reports by an individual with knowledge of the reporting requirements. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action. Cause – There was a lack of detailed review of the amounts reported on the UDS. Effect or potential effect – Inaccurate filing of reports may result in the federal program not being properly monitored, thus resulting in potential noncompliance with program requirements. Questioned costs – None Context – 1 special report was required to be submitted during the year under audit (UDS), thus this was the only report selected for testing. On this report 10 line items were tested, and of those 10 items, 1 of the lines was inaccurately reported. Identification as a repeat finding – Not a repeat finding.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00196 for project period January 1, 2023 through December 31, 2025. Criteria or specific requirement – Health centers must prepare and apply a sliding fee discount schedule that incorporates the provisions of 42 CFR 51c.303e through 56.303g to ensure that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition – The audit of the major federal program identified errors in the application of sliding fee adjustments. Cause – The sliding fee calculation was improperly set up within the Electronic Health Record System. Effect or potential effect – Inaccurate application of sliding fee adjustments may result in potential noncompliance with program requirements. Questioned costs – Not applicable Context – Out of a population of 1,478 sliding fee adjustments, a sample of 25 adjustments were tested. Out of the 25 tested, 6 adjustments were incorrectly calculated based on the Organization’s approved sliding fee scales and the patient’s sliding fee application. A non-statistical sampling methodology was used to select the sample. Identification as a repeat finding – Is a repeat finding (see 2023-001) Recommendation – We recommend that the Organization perform a review of the calculation of the sliding fee adjustments within the Electronic Health Record system to ensure it is properly set up. Additionally, we recommend that a member of management with an understanding of the Organization’s billing and sliding fee policies regularly review a sample of sliding fee adjustments in comparison to the Organization’s sliding fee policy. Views of responsible officials and planned corrective actions – See separate auditee document for planned corrective action.