Audit 408476

Finding No. 2025-001 Management is Responsible for Obtaining and Retaining Patient Intake Forms to Remain Compliant with Sliding Fee Discount Requirements. Condition: Certain patient intake forms were either not obtained or not updated for the current year’s visit. Criteria or specific requirement: Health centers are required to prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patient’s ability to pay. Adequate documentation must be maintained to support the determination and application of sliding fee discounts. Effect: Documentation supporting patient intake and eligibility for sliding fee discounts was not always retained. Cause: Of the patients selected for testing, one patient did not have an intake form on file and three patients had intake forms from years prior to 2025. This appears to be primarily due to operational transitions experienced by the Organization, which contributed to challenges in maintaining consistent execution and oversight of registration processes. Recommendation: We recommend that the Organization strengthen its procedures to ensure patient intake forms are obtained, updated as required, reviewed, approved, and retained in patient files. Management’s view: Management agrees with the condition described. Proposed corrective action: Management will strengthen procedures for obtaining and retaining patient intake documentation to ensure ongoing compliance with sliding fee discount requirements. Front-desk and registration staff will be retrained on intake form completion and annual renewal requirements, with clear accountability assigned for verifying documentation at each patient visit. A weekly compliance monitoring report will be implemented to identify missing or outdated intake forms before they age past the current review period, allowing for timely follow-up. Registration workflows will be refined to build in a review checkpoint at the point of service, and the Organization will add dedicated intake staffing capacity to provide consistent oversight of this function going forward. These steps will strengthen controls and ensure patient intake documentation is properly obtained, updated, and retained in compliance with sliding fee discount requirements. Anticipated correction date: Some corrective action was implemented in Q1 and Q2 2026. This is expected to be fully implemented effective by Q4 2026. Responsible official: Kathryn Rogers, Executive Vice President.