Audit 366700

FY End
2024-12-31
Total Expended
$2.59M
Findings
10
Programs
7
Year: 2024 Accepted: 2025-09-19
Auditor: Forvis Mazars

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
1153445 2024-002 Material Weakness Yes N
1153446 2024-003 Material Weakness Yes L
1153447 2024-002 Material Weakness Yes N
1153448 2024-003 Material Weakness Yes L
1153449 2024-002 Material Weakness Yes N
1153450 2024-003 Material Weakness Yes L
1153451 2024-002 Material Weakness Yes N
1153452 2024-003 Material Weakness Yes L
1153453 2024-002 Material Weakness Yes N
1153454 2024-003 Material Weakness Yes L

Contacts

Name Title Type
M7JBX3QK5WJ7 David Hudson Auditee
5027780001 Jennifer Williams Auditor
No contacts on file

Notes to SEFA

The accompanying schedule of expenditures of federal awards (Schedule) includes the federal award activity of the Health Center 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 Health Center, it is not intended to and does not present the financial position, changes in net assets, or cash flows of the Health Center.
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.
The Health Center has elected not to use the 10% de minimis indirect cost rate allowed under the Uniform Guidance.

Finding Details

Health Center Program Cluster; CFDA No. 93.224 and 93.527; HHS; grant number H80CS28961; budget periods June 1, 2023, through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement: Special Tests and Provisions – 42 CFR, Part 56.303(e), (f), and (g). Health Centers receiving funds under the Health Center Program Cluster are required to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay, to make every reasonable effort, including the establishment of systems for eligibility determination, billing and collection, and to secure from patient payments for services in accordance with the schedule of fees and discounts. Condition: We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 14 patients for the year ended December 31, 2024. Cause: Errors occurred when analyzing the patient accounts and the incorrect discount occurred based on the Health Center’s policy. Effect or Potential Effect: Discounts were not properly applied to patient accounts. Questioned cost: None Context: From a total of 137 sliding fee discounts for the period, 14 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended December 31, 2024. For 3 of the 14 accounts selected for testing, the account had an incorrect discount applied. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly.
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. H80CS28961 budget periods June 1, 2023 through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for a line item on its Federal Financial Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the line item. Effect or Potential Effect – The Federal Financial Report was submitted reported with potential incorrect data for line 10 (l) – Total Federal share of program income earned Questioned Costs – Not applicable Context – Out of a population of 2 financial reports required to be submitted during the year under audit, 1 financial report was tested. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Health Center Program Cluster; CFDA No. 93.224 and 93.527; HHS; grant number H80CS28961; budget periods June 1, 2023, through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement: Special Tests and Provisions – 42 CFR, Part 56.303(e), (f), and (g). Health Centers receiving funds under the Health Center Program Cluster are required to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay, to make every reasonable effort, including the establishment of systems for eligibility determination, billing and collection, and to secure from patient payments for services in accordance with the schedule of fees and discounts. Condition: We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 14 patients for the year ended December 31, 2024. Cause: Errors occurred when analyzing the patient accounts and the incorrect discount occurred based on the Health Center’s policy. Effect or Potential Effect: Discounts were not properly applied to patient accounts. Questioned cost: None Context: From a total of 137 sliding fee discounts for the period, 14 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended December 31, 2024. For 3 of the 14 accounts selected for testing, the account had an incorrect discount applied. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly.
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. H80CS28961 budget periods June 1, 2023 through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for a line item on its Federal Financial Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the line item. Effect or Potential Effect – The Federal Financial Report was submitted reported with potential incorrect data for line 10 (l) – Total Federal share of program income earned Questioned Costs – Not applicable Context – Out of a population of 2 financial reports required to be submitted during the year under audit, 1 financial report was tested. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Health Center Program Cluster; CFDA No. 93.224 and 93.527; HHS; grant number H80CS28961; budget periods June 1, 2023, through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement: Special Tests and Provisions – 42 CFR, Part 56.303(e), (f), and (g). Health Centers receiving funds under the Health Center Program Cluster are required to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay, to make every reasonable effort, including the establishment of systems for eligibility determination, billing and collection, and to secure from patient payments for services in accordance with the schedule of fees and discounts. Condition: We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 14 patients for the year ended December 31, 2024. Cause: Errors occurred when analyzing the patient accounts and the incorrect discount occurred based on the Health Center’s policy. Effect or Potential Effect: Discounts were not properly applied to patient accounts. Questioned cost: None Context: From a total of 137 sliding fee discounts for the period, 14 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended December 31, 2024. For 3 of the 14 accounts selected for testing, the account had an incorrect discount applied. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly.
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. H80CS28961 budget periods June 1, 2023 through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for a line item on its Federal Financial Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the line item. Effect or Potential Effect – The Federal Financial Report was submitted reported with potential incorrect data for line 10 (l) – Total Federal share of program income earned Questioned Costs – Not applicable Context – Out of a population of 2 financial reports required to be submitted during the year under audit, 1 financial report was tested. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Health Center Program Cluster; CFDA No. 93.224 and 93.527; HHS; grant number H80CS28961; budget periods June 1, 2023, through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement: Special Tests and Provisions – 42 CFR, Part 56.303(e), (f), and (g). Health Centers receiving funds under the Health Center Program Cluster are required to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay, to make every reasonable effort, including the establishment of systems for eligibility determination, billing and collection, and to secure from patient payments for services in accordance with the schedule of fees and discounts. Condition: We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 14 patients for the year ended December 31, 2024. Cause: Errors occurred when analyzing the patient accounts and the incorrect discount occurred based on the Health Center’s policy. Effect or Potential Effect: Discounts were not properly applied to patient accounts. Questioned cost: None Context: From a total of 137 sliding fee discounts for the period, 14 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended December 31, 2024. For 3 of the 14 accounts selected for testing, the account had an incorrect discount applied. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly.
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. H80CS28961 budget periods June 1, 2023 through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for a line item on its Federal Financial Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the line item. Effect or Potential Effect – The Federal Financial Report was submitted reported with potential incorrect data for line 10 (l) – Total Federal share of program income earned Questioned Costs – Not applicable Context – Out of a population of 2 financial reports required to be submitted during the year under audit, 1 financial report was tested. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Health Center Program Cluster; CFDA No. 93.224 and 93.527; HHS; grant number H80CS28961; budget periods June 1, 2023, through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement: Special Tests and Provisions – 42 CFR, Part 56.303(e), (f), and (g). Health Centers receiving funds under the Health Center Program Cluster are required to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay, to make every reasonable effort, including the establishment of systems for eligibility determination, billing and collection, and to secure from patient payments for services in accordance with the schedule of fees and discounts. Condition: We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 14 patients for the year ended December 31, 2024. Cause: Errors occurred when analyzing the patient accounts and the incorrect discount occurred based on the Health Center’s policy. Effect or Potential Effect: Discounts were not properly applied to patient accounts. Questioned cost: None Context: From a total of 137 sliding fee discounts for the period, 14 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended December 31, 2024. For 3 of the 14 accounts selected for testing, the account had an incorrect discount applied. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly.
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. H80CS28961 budget periods June 1, 2023 through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for a line item on its Federal Financial Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the line item. Effect or Potential Effect – The Federal Financial Report was submitted reported with potential incorrect data for line 10 (l) – Total Federal share of program income earned Questioned Costs – Not applicable Context – Out of a population of 2 financial reports required to be submitted during the year under audit, 1 financial report was tested. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.