Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the polic...
Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the policy better matches the procedures that were being implemented. • Shalom Health Care Center, Inc will be reviewing the updated Sliding Fee Discount Schedule policy and procedures with all employees. • Shalom Health Care Center, Inc will also make sure there is another level of review to make sure that the sliding fee discounts are assigned accordingly based on income and household size. Management did challenge this as being a Significant Deficiency and believes that it should be listed as a note. Management believes additional consideration should be given to the nature, scope, and impact of the exceptions before concluding that the matter constitutes a significant deficiency in compliance with 42 CFR 51c.303(f). The Organization maintained a Board of Directors approve Sliding Fee and Discount Program policy which highlight the family definition and income definition, maintained and annually updated its sliding fee discount schedule in accordance with applicable federal poverty guidelines. The issue identified by the auditors did not involve the design of the discount schedule itself or the incorporation of the federal poverty guidelines. Rather, the exceptions resulted from staff members applying an interpretation of family size that differed from the definition established in the Organization's internal policy when processing individual applications. Accordingly, management believes the audit report should clearly distinguish between an error in applying the Organization's internal methodology and a violation of a federal compliance requirement. Management has requested that the auditors identify the specific provision of 42 CFR 51c.303(f) that was allegedly violated in each of the three cited cases. Management does agree that the procedures did not follow the policy and that this is more of an issue of process and controls. Management respectfully disagrees with the Finding 2025-001, particularly the classification given as a Significant Deficiency and the characterization of the exceptions as noncompliance with the federal requirement cited in the finding. Management requested the auditors to reconsider whether the circumstances support classification as a Significant Deficiency. At a minimum, management requests that the finding clearly distinguish between (1) compliance with the federal requirement and (2) the Organization's internal procedures for determining family size and calculating the sliding fee discount. Based on the limited number of exceptions, the absence of questioned costs, the lack of evidence of intentional noncompliance, and the fact that the Organization maintained and updated its sliding fee schedule in accordance with the applicable poverty guidelines, management believe that the finding should have given a lesser finding classification and a note in the audit report.)