Audit 395197

Criteria: Federal regulations require non-federal entities to maintain records that adequately support allowable costs and program activities. Specifically, 2 CFR 200.302 requires financial management systems to provide accurate, current, and complete disclosure of financial results, and 2 CFR 200.403 requires that costs charged to federal awards be allowable, reasonable, and adequately documented. HRSA program requirements further require health centers to maintain patient-level documentation to support reported encounters and costs. Condition: During audit testing of patient eligibility and sliding fee scale application, supporting documentation of income was not available for 25 of 40 patients sampled. As a result, the health center was unable to demonstrate that the sliding fee discounts were appropriately determined in accordance with program requirements. Cause: Per HRSA and UDS requirements, FQHC’s must determine patient eligibility for the sliding fee discount based on income and family size, and retain documentation to support income verification for each patient applying for the discount. Effect: As a result, the health center is in noncompliance with HRSA sliding fee discount program requirements, which represents a material weakness in internal control over compliance and results in an increased risk that patients received sliding fee discounts for which they were not eligible or that eligible patients were improperly classified, and that Uniform Data System (UDS) data related to patient income levels and sliding fee discount utilization may be materially misstated. Questioned Costs: Questioned costs could not be determined due to the lack of supporting documentation for the affected patients. Recommendation: We recommend that management reinforce policies requiring documentation of income and family size before applying sliding fee discounts, implement periodic review of patient files to ensure compliance, provide staff training, and accountability measures for intake procedures, and consider adding monitoring on a quarterly basis to ensure ongoing adherence.

Criteria: Federal regulations require non-federal entities to maintain records that adequately support federal program reporting. Specifically, 2 CFR 200.302 requires recipients to maintain financial and programmatic records that provide accurate, current, and complete disclosure of program results, and 2 CFR 200.333 requires records to be retained and available for audit. HRSA Health Center Program requirements further require health centers to maintain documentation supporting data reported in the Uniform Data System (UDS), including patient-level records supporting Table 4 – Selected Patient Characteristics. Condition: The health center did not provide a report or reconciliation that ties source data to the totals reported in UDS Table 4 – Selected Patient Characteristics. Management provided a report based on billable visits and patients only, which excluded visits and patients for which no charge was associated. Management stated that UDS data are pulled directly from the electronic health record system (eClinicalWorks) by the compliance department using system mapping that differs from billing reports, and that the mapping will not change. As a result, the auditors were unable to verify that all patients required to be included in Table 4 were captured and accurately reported. Cause: The health center did not have documentation available to validate the accuracy and completeness of the UDS Table 4 data. Effect: Because a reconciliation or alternative audit trail was not available, the auditors were unable to determine whether UDS Table 4 data were complete and accurate, including whether non-billable patients were appropriately included. This condition increases the risk that the UDS report contains incomplete or inaccurate patient characteristic data, which may affect HRSA’s oversight, monitoring, and funding determinations. Questioned Costs: No questioned costs are reported for this finding, as the UDS report represents programmatic reporting and does not directly result in identifiable questioned costs. Recommendation: We recommend that management establish and document controls over UDS reporting, including developing reconciliations or alternative audit trails that demonstrate completeness of patient populations reported in Table 4, documenting system mapping and logic used to generate UDS data, and implementing management review procedures prior to UDS submission.