Audit 407509

Finding No. 2025-001 – Late Report Filling Federal Program Health Center Program Cluster ALN 93.224 Name of Federal Agency U.S. Health and Human Services Compliance Requirement Reporting Type of Finding: Significant deficiency in internal control over compliance Criteria Title 2 CFR §200.328(a) requires the Federal Financial Report (SF-425). Payment Management System (PMS) HRSA require the recipient or subrecipient must submit financial reports as required by the Federal award. Reports submitted annually by the recipient or subrecipient must be due no later than 90 calendars days. Condition During our review of the SF-425 submitted reports, we noted that one of the reports was submitted after the 90-day requirement. Context From a sample of two (2) financial reports submitted during the fiscal year ended September 30, 2025, one was filed late. Cause The condition was caused by deficiencies in internal control over compliance. Management did not establish adequate monitoring procedures to ensure required reports were prepared and submitted by the applicable deadlines and ensure timely preparation, review, and submission of required reports. Effect Lack of report submission or a delay on report submission may result in regulatory penalties and or additional administrative costs. Questioned Costs There were no questioned costs associated with this finding. Identification as a Repeated Finding This is not a repeat finding from the immediate previous audit. Recommendation We recommend that management strengthen internal controls over the filing process by establishing formal procedures to monitor reporting deadlines, assign responsibility for preparation and review activities, and ensure required filings are submitted in a timely manner. Management should also implement a tracking mechanism, such as a compliance calendar or automated reminders, to improve oversight and prevent future delays. Views of responsible Officials (Unaudited) Refer to the corrective action plan on pages 47-50.

Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Programs Health Center Program Cluster ALN 93.224 Federal Agency U.S. Health and Human Services (HHS) Compliance Requirement Special Test and Provisions Finding Type Significant deficiency in Internal Control over Compliance Criteria According to the Sliding Fee Discount Program of the HRSA Health Center Program Compliance Manual, Chapter 9, health centers are required to maintain and implement a Sliding Fee Discount Program (SFDP) that is based on current Federal Poverty Guidelines (FPG) issued annually by the U.S. Department of Health and Human Services (HHS). HRSA Compliance Manual requirements further establish that health centers must: • Update Federal Poverty Guidelines annually; • Apply discounts uniformly and consistently; • Maintain documented policies and procedures governing SFDP eligibility determinations; • Retain supporting documentation for income and household size verification. Additionally, Section 330(k)(3)(G) of the Public Health Service Act and 42 CFR § 51c.303(f) require health centers to establish and consistently apply schedules of discounts adjusted to the patient’s ability to pay, based on family size and income. Condition During the review of patient files, SFDP determinations, and administrative documentation, it was identified that the entity utilized an incorrect sliding fee discount percent based on Federal Poverty Guidelines when determining patient eligibility. Furthermore, the entity was unable to provide sufficient evidence demonstrating, adequate internal controls to validate eligibility determinations. As a result, the patient accounts reviewed reflected unsupported or inaccurate discount determinations. Context From a sample of forty (40) patient files, two (2) patients Federal Poverty Guidelines were incorrectly applied to the sliding fees discount determined. Cause The finding occurred because management did not establish adequate procedures to review and monitoring controls over eligibility determinations which contributed to the use of outdated or incorrect discount calculations. In addition, there were insufficient internal controls to ensure the most current Federal Poverty Guidelines were consistently incorporated into the Sliding Fee Discount Program. Effect Failure to properly apply current Federal Poverty Guidelines increases the risk of: • Inaccurate patient eligibility determinations; • Improper application of sliding fee discounts; • Noncompliance with HRSA Health Center Program requirements; • Financial misstatements related to program income and patient fee collections; • Potential repayment liabilities, questioned costs, or adverse audit and compliance monitoring findings; • Increased risk of HRSA enforcement actions or corrective action requirements. Given the nature of the deficiencies identified and the absence of adequate compensating controls, this matter is considered a Significant Deficiency in internal control over compliance. Questioned Costs The known questioned cost is $245.97, the amount in Health Center Program funds claimed on the participant whose eligibility could not be adequately supported. Identification as a Repeated Finding This is not a repeat finding from the immediate previous audit. Recommendation Management should immediately implement corrective actions to ensure compliance with HRSA Sliding Fee Discount Program requirements, including: 1. Updating and implementing current Federal Poverty Guidelines issued by HHS; 2. Revising all applicable Sliding Fee Discount schedules and eligibility procedures; 3. Conducting a retrospective review of SFDP determinations affected by outdated guidelines; 4. Strengthening internal controls over annual updates, approvals, and monitoring processes; 5. Providing formal training to staff responsible for SFDP eligibility determinations; 6. Maintaining complete and auditable documentation supporting all discount determinations and annual updates. Views of Responsible Official (Unaudited) Refer to the corrective action plan on pages 47-50.

Finding No. 2025-003 - Late Filing of Single Audit Reporting Package Federal Programs Health Center Program Cluster ALN 93.224 Federal Agency U.S. Health and Human Services (HHS) Compliance Requirement Reporting Type of Finding Internal Control over Compliance Category Significant Deficiency Criteria As required by the audit requirements of Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), § 200.512 Report submission (a) (1), “ the audit must be completed and the data collection form described in paragraph (b) of this section and reporting package described in paragraph (c) of this section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or Federal holiday, the reporting package is due the next business day”. Condition The Hospital has not submitted the Single Audit Reporting Package for the year ended September 30, 2025. Cause Delays in the completion of accounting procedures and the untimely delivery of supporting financial information to the auditors resulted in a delayed completion of the Single Audit and subsequent late submission to the Federal Audit Clearinghouse. Effect The entity was not in compliance with the reporting requirements of the Uniform Guidance, which may impair the ability of federal agencies and pass-through entities to perform timely monitoring and oversight of federal awards. Questioned Costs None. Identification as a Repeated Finding This is not a repeat finding. Recommendation Management should implement procedures to ensure the timely completion of accounting processes and the timely delivery of financial records and supporting documentation so that the audit reporting package can be submitted to the Federal Audit Clearinghouse by the required due date. Views of Responsible Official (Unaudited) Refer to the corrective action plan on pages 47-50.