Audit 373376

Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Year 17 and 18 Family Planning Services – ALN No. 93.217 U.S. Department of Health and Human Services Award No. FPHPA006584 Program Year 3 and 4 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year for the Health Center Program Cluster and to prepare and submit quarterly Federal Cash Transaction Reports (FCTR) for each grant budget period for the Family Planning Services awards. These reports are to be prepared using accurate financial information. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Effect or potential effect– Potential errors were made on the annual UDS report and Family Planning Services FFR reports. Questioned cost – None Context – The annual UDS and FFR reports for the Health Center Program Cluster and four quarterly FCTR reports for the Family Planning Services awards were selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the ten inputs tested, two exceptions were noted related to the annual UDS report. Of the four reports, three reports including exceptions were noted in the quarterly Family Planning services reports. Identification as a Repeat Finding – Yes, findings 2024-002 and 2023-009. Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained. Views of Responsible Officials and Planned Corrective Actions – CCI Health Services will strengthen its processes to ensure all UDS, FFR, and FCTR reports are prepared using accurate financial information supported by appropriate documentation. A standardized federal reporting checklist is being developed to identify required data sources, outline reconciliation steps, and document preparer and reviewer responsibilities. All reports will be reconciled to the system reports and reviewed by both the Controller and CFO before submission to ensure accuracy and completeness. Supporting documentation for all federal reports will be maintained in a centralized location to ensure consistency and future audit readiness. Anticipated Completion/Implementation Date: End of Fiscal Year 2025

Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received sliding fee discounts that were inconsistent with the stated sliding fee discount categories under the Organization's policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect – Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee discount policy. Questioned cost – None Context – A sample of 40 encounters were tested out of the total population of 131,107 encounters. The sampling methodology used is not and is not intended to be statistically valid. Twenty patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their family size and household income documentation. Identification as a repeat finding, if applicable – Yes, finding 2024-003. Recommendation – We recommend management 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 and the Health Center Program Compliance Manual. Views of Responsible Officials and Planned Corrective Actions – CCI is implementing a system update within eCW to ensure the sliding fee schedule is accurately configured and consistently applied across all service locations. As part of this corrective action, CCI is developing a formal training program to ensure that all applicable employees understand the sliding fee requirements and possess the necessary knowledge to follow the established procedures. CCI is also establishing an internal review process to monitor compliance with the sliding fee policy. This process will include periodic sampling and review of sliding fee scale assessments to verify that eligibility determinations and discounts are being applied correctly and in accordance with policy. Any identified discrepancies will be addressed through targeted staff retraining or process adjustments, as appropriate. These corrective actions are designed to strengthen internal controls, ensure consistent application of the sliding fee program, and maintain compliance with regulatory and organizational requirements. Anticipated Completion/Implementation Date: End of Fiscal Year 2026