12/16/2024
United States Department of Health and Human Services
Betty Jean Kerr – People’s Health Centers respectfully submits the following corrective action plan for the
year ended May 31, 2024.
CohnReznick LLP
350 Church Street
Hartford, CT 06103
Audit Period: May 31, 2024
The findings from th...
12/16/2024
United States Department of Health and Human Services
Betty Jean Kerr – People’s Health Centers respectfully submits the following corrective action plan for the
year ended May 31, 2024.
CohnReznick LLP
350 Church Street
Hartford, CT 06103
Audit Period: May 31, 2024
The findings from the May 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule.
FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS
Section III‐ Federal Award Findings and Questioned Costs
Community Health Centers, Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program, COVID-19 Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527
Item 2024‐001 – Special Tests
Recommendation
The Center should establish a system of internal controls to ensure that all slide fee discounts are properly calculated based on family size and income.
Repeat Finding
Yes
Action Taken
1. Upon notification of findings, new reporting structures and training were developed for the FOA staff. Direct governance was moved from finance to operations, and the scheduling supervisor was promoted to a newly created role entitled the Director of Patient Access. This role is directly responsible for training and the scheduling of FOA staff as well as data integrity of registration information.
2. Once developed, we provided targeted training sessions for all staff involved with the calculation of sliding fees on the policies and procedures to ensure:
The sliding fee guidelines document is known.
Understanding of the methodology for calculating fees, including how family size and income are considered.
Documentation required to support income and family size information provided by clients. This may include tax returns, pay stubs, or other relevant documents.
To use the standardized form (checklist) to ensure all necessary information is collected and verified.
3. We also have implemented a monthly audit process that randomly selects a sample of sliding fee patients. Selected patients’ files are reviewed to identify any potential discrepancies. If discrepancies
are noted, prior to remediation, errors are documented so that thematic analysis can be conducted, and root causes can be identified. To ensure traction of the initiative, audit findings are presented monthly to the quality assurance and performance improvement committee.
4. We make every effort we can to effectively communicate the sliding fee scale to clients. In addition to face-to-face communication, it is presented openly in several locations throughout the agency and is also available on our website. We are aware that ensuring the continued compliance of the SFS scale determinations, as well as the financial accuracy of our books requires consistent and continuous commitment to quality and
improvement. We are confident that the changes made to our internal controls will significantly strengthen our processes. We believe these measures will mitigate the risk of errors and inaccuracies in the future,
providing greater assurance over the reliability of our financial reporting.
If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Javier Vallejo,
CFO at 314-482-0915.
Sincerely yours,
Javier Vallejo
Chief Financial Officer