As required by OMB Uniform Guidance, we have provided below our response and corrective action plan addressing the findings in the “Report on Federal Awards in Accordance with the OMB Uniform Guidance” for the year ended June 30, 2025. Management’s Views and Corrective Action Plan Finding 2025-001 –...
As required by OMB Uniform Guidance, we have provided below our response and corrective action plan addressing the findings in the “Report on Federal Awards in Accordance with the OMB Uniform Guidance” for the year ended June 30, 2025. Management’s Views and Corrective Action Plan Finding 2025-001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance It was identified during the current year audit that while the Organization successfully implemented system-level enhancements within their electronic health record system to consistently apply appropriate sliding fee discounts (previously a noted deficiency), the internal control environment remains inconsistently applied. The Organization’s front office staff responsible for patient intake did not obtain the necessary qualification criteria, or incorrectly billed patients under the sliding fee discount schedule. As a result, they did not consistently apply the appropriate sliding fee discounts for patients based on qualification criteria and certain patients were billed for the incorrect amounts under the sliding fee discount schedule. This was primarily due to administrative lapses and high staff turnover, which have hindered the full implementation of training protocols and eligibility documentation requirements. To address the finding related to patient intake that resulted in patients being billed for incorrect amounts specified in the sliding fee discount schedule, the Organization will implement a comprehensive corrective action plan. The Organization is actively developing and delivering targeted training for front office staff on the application of sliding fee discounts. The Organization partnered with its electronic health record vendor, OCHIN, to implement a Financial Assistance Module which will create the system a revenue cycle staff person will use to review each sliding fee scale application for completeness prior to approving patient access to sliding fee discounts. Additionally, the Organization also plans to update policies and procedures to incorporate monthly internal monitoring, reviews of data capture accuracy, and administrative oversight of sliding fee discount application to strengthen internal controls. Finally, thorough documentation of all corrective actions taken will be maintained. The Chief Financial Officer will report findings to management monthly. Through these measures, the Organization aims to enhance billing accuracy, ensure compliance with federal requirements, and prevent future discrepancies. Anticipated Date of Corrective Action: July 31, 2026 Party Responsible for Corrective Action: Molly Jouaneh, Chief Financial Officer