Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information. Questioned costs – None Context – Two reports from those listed above were selected for testing. The sampling methodology used is not, and was not intended, to be statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and three exceptions were noted related to the annual FFR. Effect – Errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Turnover in key positions resulted in the Organization being unable to support the total of five attributes selected for testing on both the UDS report and annual FFR. Identification as a repeat finding – Repeat of 2021-002 finding Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Questioned costs – None Context – A sample of 40 patients were tested out of the total population of 41,445 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 4 were determined to include errors in the application of the sliding fee discount program and policy. Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Cause – The Organization did not comply with their sliding fee discount policy. Identification as a repeat finding – Repeat finding of finding 2021-003 Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information. Questioned costs – None Context – Two reports from those listed above were selected for testing. The sampling methodology used is not, and was not intended, to be statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and three exceptions were noted related to the annual FFR. Effect – Errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Turnover in key positions resulted in the Organization being unable to support the total of five attributes selected for testing on both the UDS report and annual FFR. Identification as a repeat finding – Repeat of 2021-002 finding Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Questioned costs – None Context – A sample of 40 patients were tested out of the total population of 41,445 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 4 were determined to include errors in the application of the sliding fee discount program and policy. Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Cause – The Organization did not comply with their sliding fee discount policy. Identification as a repeat finding – Repeat finding of finding 2021-003 Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information. Questioned costs – None Context – Two reports from those listed above were selected for testing. The sampling methodology used is not, and was not intended, to be statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and three exceptions were noted related to the annual FFR. Effect – Errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Turnover in key positions resulted in the Organization being unable to support the total of five attributes selected for testing on both the UDS report and annual FFR. Identification as a repeat finding – Repeat of 2021-002 finding Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Questioned costs – None Context – A sample of 40 patients were tested out of the total population of 41,445 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 4 were determined to include errors in the application of the sliding fee discount program and policy. Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Cause – The Organization did not comply with their sliding fee discount policy. Identification as a repeat finding – Repeat finding of finding 2021-003 Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information. Questioned costs – None Context – Two reports from those listed above were selected for testing. The sampling methodology used is not, and was not intended, to be statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and three exceptions were noted related to the annual FFR. Effect – Errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Turnover in key positions resulted in the Organization being unable to support the total of five attributes selected for testing on both the UDS report and annual FFR. Identification as a repeat finding – Repeat of 2021-002 finding Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Questioned costs – None Context – A sample of 40 patients were tested out of the total population of 41,445 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 4 were determined to include errors in the application of the sliding fee discount program and policy. Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Cause – The Organization did not comply with their sliding fee discount policy. Identification as a repeat finding – Repeat finding of finding 2021-003 Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information. Questioned costs – None Context – Two reports from those listed above were selected for testing. The sampling methodology used is not, and was not intended, to be statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and three exceptions were noted related to the annual FFR. Effect – Errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Turnover in key positions resulted in the Organization being unable to support the total of five attributes selected for testing on both the UDS report and annual FFR. Identification as a repeat finding – Repeat of 2021-002 finding Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Questioned costs – None Context – A sample of 40 patients were tested out of the total population of 41,445 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 4 were determined to include errors in the application of the sliding fee discount program and policy. Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Cause – The Organization did not comply with their sliding fee discount policy. Identification as a repeat finding – Repeat finding of finding 2021-003 Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data Set (UDS) report for each calendar year, and annual Federal Financial Report (FFR) for each grant year and quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period. These reports are to be prepared using accurate financial information. Questioned costs – None Context – Two reports from those listed above were selected for testing. The sampling methodology used is not, and was not intended, to be statistically valid. Of the eighteen inputs tested, two exceptions were noted related to the UDS report and three exceptions were noted related to the annual FFR. Effect – Errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Turnover in key positions resulted in the Organization being unable to support the total of five attributes selected for testing on both the UDS report and annual FFR. Identification as a repeat finding – Repeat of 2021-002 finding Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information.
Federal Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 5 H80CS04226-17-00 Program Year 2022 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Questioned costs – None Context – A sample of 40 patients were tested out of the total population of 41,445 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 40 transactions tested, 4 were determined to include errors in the application of the sliding fee discount program and policy. Effect – Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Cause – The Organization did not comply with their sliding fee discount policy. Identification as a repeat finding – Repeat finding of finding 2021-003 Recommendation – The Organization should continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Federal Assistance Listing Number 93.243 U.S. Department of Health and Human Services Criteria or Specific Requirement – Cash Management (45 CFR 75.305) Condition – The Organization’s internal controls over compliance were not able to prevent an advance drawdown. Questioned Costs – None Context – Out of a population of twenty-four draws, a sample of six draws were selected for testing. The sampling methodology used was not, and was not intended to be, statistically valid. Of the six draws tested, four draws were considered advanced draws Effect – Grant funds were drawn down sooner than administratively necessary. The four draws were not earned as of the end of three days prior to disbursement of allowable expenditures. Cause – The Organization was struggling to maintain adequate cash reserves and therefore advance drew on the award, with the knowledge that allowable expenditures would be incurred and covered by the draws in future periods. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – The Organization should ensure procedures are followed to prevent cash draws from being drawn sooner than three days prior to disbursement of allowable expenditures.