Audit 380589

Federal Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS28372-09-00 Program Year 2024 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial and operational data. Cause – The Organization's policies and procedures in effect did not accurately report program income, program income expended and unexpended program income. Effect or potential effect – Potential errors were made on the FFR. Questioned costs – None Context – Each report listed above was selected for testing with specific data from each report identified for testing. The sampling methodology used is not, and was not intended, to be statistically valid. Of the eighteen inputs tested, three exceptions were noted related to the FFR. Identification as a repeat finding – Repeat finding, see prior year finding number 2023-003. Recommendation – The Organization should revise its policies and procedures over Federal reporting to ensure reports are prepared using accurate information financial reporting standards.

Federal Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS28372-10-01 Program Year 2024 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 section 56.303(f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause –The Organization did not comply with their sliding fee discount policy. Effect or potential effect – Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 40 patient encounters was tested out of the population of 8,900 patient encounters. The sample is not, and is not intended to be, statistically valid. Of the 40 patient encounters tested, two were determined to have resulted in an improper sliding fee adjustment based on the Organization’s policy and screening of patient eligibility. Identification as a repeat finding – Repeat finding, see prior year finding number 2023-004. Recommendation – Management should ensure that sliding fee adjustments are properly applied in accordance with the sliding fee policy and patient eligibility.