Audit 6064

FY End
2023-06-30
Total Expended
$3.91M
Findings
16
Programs
8
Year: 2023 Accepted: 2023-12-11
Auditor: Terry Horne CPA

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
3849 2023-002 Material Weakness Yes N
3850 2023-002 Material Weakness Yes N
3851 2023-002 Material Weakness Yes N
3852 2023-002 Material Weakness Yes N
3853 2023-003 Material Weakness Yes I
3854 2023-003 Material Weakness Yes I
3855 2023-003 Material Weakness Yes I
3856 2023-003 Material Weakness Yes I
580291 2023-002 Material Weakness Yes N
580292 2023-002 Material Weakness Yes N
580293 2023-002 Material Weakness Yes N
580294 2023-002 Material Weakness Yes N
580295 2023-003 Material Weakness Yes I
580296 2023-003 Material Weakness Yes I
580297 2023-003 Material Weakness Yes I
580298 2023-003 Material Weakness Yes I

Contacts

Name Title Type
Y3DJYKS5KDF5 Shantelle Simpson Auditee
8283543402 Terry Horne Auditor
No contacts on file

Notes to SEFA

Title: Presentation Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The Organization has elected not to use the 10 percent de minimus indirect cost rate allowed under Uniform Guidance. De Minimis Rate Used: N Rate Explanation: N/A Basis of presentation described
Title: Subrecipients Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The Organization has elected not to use the 10 percent de minimus indirect cost rate allowed under Uniform Guidance. De Minimis Rate Used: N Rate Explanation: N/A Statement regarding use of subrecipients

Finding Details

Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts or incorrect family size was entered for 2 patients out of a sample of 20 patients during the year ended June 30, 2023. Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to certain patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: For 2 of 20 self-pay patients selected for testing, the account had an incorrect discount applied or the family size incorrectly entered. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024
Finding: 2023-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were obtained as required. Effect: The Organization did not verify that certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that the Organization establish procedures to ensure that the procurement policy is followed and that debarment searches are performed and documented as required. Views of Responsible Officials: Management concurs. Management will verify that employees are not suspended, debarred or otherwise excluded from participating in federal programs. Contact Person: Shantelle Simpson, CEO Anticipated Date of Completion: January 31, 2024