Finding 1160214 (2024-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2025-10-09
Audit: 370598
Auditor: Dza PLLC

AI Summary

  • Core Issue: Incorrect sliding fee discounts were applied to eligible patients, indicating a systemic compliance problem.
  • Impacted Requirements: This violates Title 2 U.S. CFR Part 200, which mandates accurate application of sliding fee schedules based on patients' ability to pay.
  • Recommended Follow-Up: Enhance training for staff on applying discounts correctly and implement a review process for patient accounts to ensure compliance and proper documentation.

Finding Text

Federal Organization: U.S Department of Health and Human Services Assistance Listing Numbers: 93.224 and 93.527 Health Center Program Cluster Award Numbers: H80CS24102, H8LCS51030, H8GCS47827, H2ECS45503 Criteria: [X] Compliance Finding [X] Significant Deficiency [ ] Material Weakness Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart F, Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patients ability to pay.” Condition: During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified three incidents in which the incorrect sliding fee was applied. Context: This finding appears to be a systemic issue. A sample size of 25 patients included three which did not have the correct sliding fee applied. Cause: The Organization did not follow its policies and procedures set in place to ensure the sliding fee schedule discount is correctly determined and applied to patient accounts. Effect Patients: may have been granted the incorrect sliding fee discount. Questioned Costs: None identified Recommendation: We recommend continued effort in training personnel to properly identify and apply the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. Views of responsible officials and planned corrective action: Management does not disagree with this audit finding.

Corrective Action Plan

Corrective action planned: In reviewing audit finding 2024-001, it was determined that the primary cause for the misapplication of the sliding fee was the need for increased training and oversight. One Health has since taken steps to enhance sliding fee policy and procedure training for all staff, with a focus on Intake and Patient Financial Services staff. One Health also intends to review individual performance of staff by implementing peer and supervisory audits of sliding fee scale applications and data entry. Identification of consistent errors has led to enacting accountability measures to allow for additional coaching and follow-up. Additionally, One Health has reviewed EMR processes and functionality to ensure ease and clarity of data entry to eliminate opportunities for human error. Anticipated completion date: December 31, 2025 Contact person responsible for corrective action: Emily Faricy Associate Vice President - Finance

Categories

Special Tests & Provisions Allowable Costs / Cost Principles Material Weakness Significant Deficiency

Other Findings in this Audit

  • 1160213 2024-001
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $8.09M
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $2.14M
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $803,160
93.527 Grants for New and Expanded Services Under the Health Center Program $560,495
93.526 Grants for Capital Development in Health Centers $268,419
93.788 Opioid Str $247,503
93.959 Block Grants for Prevention and Treatment of Substance Abuse $227,281
66.818 Brownfields Multipurpose, Assessment, Revolving Loan Fund, and Cleanup Cooperative Agreements $219,659
93.268 Immunization Cooperative Agreements $161,787
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $112,403
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $108,534
93.870 Maternal, Infant and Early Childhood Home Visiting Grant $105,914
93.958 Block Grants for Community Mental Health Services $103,192
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $88,991
21.027 Coronavirus State and Local Fiscal Recovery Funds $68,250
32.006 Covid-19 Telehealth Program $52,500
93.110 Maternal and Child Health Federal Consolidated Programs $49,497
93.069 Public Health Emergency Preparedness $30,565
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $13,327
93.994 Maternal and Child Health Services Block Grant to the States $12,990
93.217 Family Planning Services $10,222
93.236 Grants to States to Support Oral Health Workforce Activities $7,781
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $6,981
93.967 Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health $4,882
93.988 Cooperative Agreements for Diabetes Control Programs $1,078