Finding F2025-001 – Incorrect Application of Sliding Fee Discounts (Repeat Finding) Assistance Listing Number: 93.224 Assistance Listing Program Title: Health Center Program Cluster Federal Agency: U.S. Department of Health and Human Services (HHS) - Health Resources and Services Administration (HRSA) Pass Through Entity: Not applicable Federal Award Number: H80CS06647-19-05 H80CS06647-20-03 H8FCS41285-01-04 Federal Award Year: January 1, 2024 to December 31, 2024 January 1, 2025 to December 31, 2025 April 1, 2021 to December 31, 2024 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Criteria or Specific Requirements Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines. Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project. Condition El Proyecto del Barrio, Inc. (El Proyecto) determines the amount of fees to be charged to a patient based on the patient’s income, expenses, and number of dependents in conjunction with the sliding fee schedule. Of the 40 patients selected for testwork, we noted the following: • 7 patients were charged an incorrect sliding fee amount, which resulted in undercharging the patients by a total of $663. These errors were due to the incorrect patient income amount used to calculate the sliding fee amount. The patient’s net income or net pay was incorrectly used to determine the sliding fee amount instead of the patient’s gross income per the income tax return, pay stub, or earnings statement. • 9 patients had no proof of income declaration. Therefore, there was no formal documentation to support the determination of the patient’s sliding fee amount. This resulted in undercharging the patients by a total of $1,674. • 1 patient had no application form on file but had a record in the system. Therefore, the patient’s sliding fee amount could not be verified as the supporting documentation (income and family size per the application form) was not available. This resulted in undercharging the patient by a total of $148. • 4 patients’ income amount per the system did not agree to the income amount per the patients’ application forms and the patients’ supporting documentation on file (earnings statements). This error had no impact on the sliding fee calculation. • 1 patient’s gross income amount was incorrect in the system. The gross income amount was incorrectly determined by staff based on one month's income instead of two weeks per the patient’s bi-weekly earnings statement and was understated by $4,320. This error had no impact on the sliding fee calculation. • 1 patient’s gross income did not reflect the total gross household income (i.e., spousal income was not declared) per the affidavit of income support. However, the total gross household income was correctly declared per the sliding fee application, resulting in a gross income understatement of $24,000. This resulted in undercharging the patient by a total of $70. • 2 patients’ family size was incorrectly coded as account numbers in the sliding fee application due to an input error by the patient. Thus, we were unable to verify the total household size. This error had no impact on the sliding fee calculation. Questioned Costs The total gross amount undercharged to patients was $2,555. Note that this amount represents lost revenues to El Proyecto. Such lost revenues are not claimed for reimbursement under the grant. The grant drawdown requests solely represent requests for reimbursement of El Proyecto’s actual costs incurred under the program (such as salaries). Cause The causes of the above errors are as follows: • Errors by staff in properly determining the patient’s ability to pay. • Incorrect patient income information was input into the system. • Lack of a supervisor review process and maintenance of income declaration forms. • High turnover of clinical staff and a lack of sufficient training. Effect Such errors may result in an incorrect determination of the patient’s ability to pay, incorrect fee amounts charged to patients, and noncompliance with federal grant requirements. Recommendation We recommend that El Proyecto’s controls and procedures be strengthened to ensure that income declaration is properly verified and adequately documented, and that the sliding fee discount is properly determined and applied. This should include incorporating additional procedures, as necessary, on the existing checklist used to determine the patient’s sliding fee amount, formal supervisory review of the checklist, and additional training for all staff involved in the sliding fee review process. This will help ensure that 1) there is proper monitoring and review of compliance with program requirements, and 2) proper determination of the sliding fee amount charged to patients. Views of Responsible Officials and Planned Corrective Actions El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, the following corrective actions are being implemented: 1. Revised Application and Documentation Requirements: o The Sliding Fee Program application forms are being updated to include structured sections for staff to record income from supporting documentation (e.g., pay stubs, tax returns), rather than relying on the patient to write their income on the application, which will greatly reduce incorrect income stated on support. Staff will be responsible for calculating annual gross income based on supporting documentation and have a checklist to ensure documentation is complete and retained/uploaded in the system. 2. Two-Step Review Process: o A staff member (the “Preparer) will calculate the annual gross income, determine the household size, and determine the eligible sliding fee discount, and a second staff member (the “Reviewer”) will independently review and verify the Preparer’s calculations and determinations based on the supporting documentation. Both parties will document their review of the application to establish accountability. 3. Staff Training and Ongoing Competency Checks: o Comprehensive refresher training will be provided to all staff involved in the sliding fee program process, including the use of the poverty guidelines, income calculation methods, the new forms, entering income and household size into the system, and uploading support to the system. 4. Formal Ongoing Monitoring and Review: o The Billing Department will conduct regular audits of completed sliding fee applications and eligibility determination forms to ensure compliance with policies. Errors will be tracked and addressed through corrective action and coaching. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: August 31, 2026
Finding F2025-003 – Untimely Submission of Reports Assistance Listing Number: 93.526 Assistance Listing Program Title: Grants for Capital Development in Health Centers Federal Agency: U.S. Department of Health and Human Services – Health Resources and Services Administration (HRSA) Pass Through Entity: Not applicable Federal Award Number: C8ECS44046-01-06 Federal Award Year: September 15, 2021 to September 30, 2025 Compliance Requirement: Reporting Criteria Per 2 CFR §200.328, non-Federal entities must submit accurate and complete Federal Financial Reports (FFRs) in accordance with program requirements. HRSA requires timely submission of financial and program reports as specified in the Notice of Award (NOA), typically within 90 or 120 days after the end of the reporting period. Condition In performing reporting compliance testwork, we noted that the federal financial report (FFR) for the grant reporting period for the year ended September 30, 2025 was not submitted by the required due date. The FFR is due on January 28, 2026. The FFR was submitted 8 days late. Cause The delay resulted from an internal oversight by grant program personnel during the award closeout process. While HRSA granted a time extension for El Proyecto to complete and submit required closeout documentation, management’s efforts were primarily directed towards meeting the extended closeout requirement due date. The annual FFR due date, which is separate from the closeout documentation deadline, was not separately granted an extension by HRSA. Due to the internal oversight and lack of formal monitoring of grant program submission dates, the FFR was submitted beyond the submission due date. Effect Late submission of required grant reports will result in noncompliance with federal grant reporting requirements and may impact future grant funding. Questioned Costs Not applicable. Recommendation We recommend that El Proyecto strengthen its controls to ensure compliance with grant reporting requirements, as specified in the award documents. We recommend that El Proyecto develop a tracking schedule for grant report submission due dates, maintain formal documentation of reports submitted, increase management oversight, monitoring, and review procedures, and perform additional staff training, as needed, regarding federal grants reporting requirements. Views of Responsible Officials and Planned Corrective Actions Management acknowledges the finding. El Proyecto has implemented corrective actions, including tracking the FFR submission due dates separately from any closeout documentation submission due dates to help ensure both requirements are monitored and completed within the required timeframes. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: June 1, 2026