Finding 1162290 (2024-003)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2025-11-13
Audit: 372114
Organization: Waikiki Health (HI)
Auditor: COHNREZNICK LLP

AI Summary

  • Core Issue: The Center lacks proper documentation and controls for sliding fee discounts, leading to incorrect calculations.
  • Impacted Requirements: Compliance with federal guidelines for determining patient eligibility and applying discounts based on income and family size.
  • Recommended Follow-Up: Implement stronger internal controls and monitor compliance to ensure accurate sliding fee calculations and documentation.

Finding Text

Finding 2024.003: Special Tests and Provisions - Sliding Fee Scale Documentation - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID-19 - Health Center Program Cluster: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Federal Assistance Listing Numbers: 93.224 Federal Award Identification Number and Year: H80CS00053 - 2023 and 2024, H8FCS41422 - 2023 Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Condition The Center did not always have the proper slide fee documentation readily available to ensure the proper slide fee discount was applied based on approved policies or the discount was calculated incorrectly. Cause The Center did not have adequate internal controls in place to effectively ensure that all sliding fee discounts were properly calculated based on approved documentation. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None Context A test of 40 sliding fee discount transactions was performed and resulted in 20 instances where the Center was unable to provide approved documentation, or the sliding fee discount was calculated incorrectly. Our sample was a statistically valid sample. Identification of Repeat Finding This finding is a repeat finding (see prior year finding number: 2023.003) Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency. Management has prepared a Corrective Action Plan that outlines the additional controls implemented.

Corrective Action Plan

Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.

Categories

Special Tests & Provisions Subrecipient Monitoring Eligibility HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1162286 2024-003
    Material Weakness Repeat
  • 1162287 2024-004
    Material Weakness Repeat
  • 1162288 2024-005
    Material Weakness Repeat
  • 1162289 2024-006
    Material Weakness Repeat
  • 1162291 2024-004
    Material Weakness Repeat
  • 1162292 2024-005
    Material Weakness Repeat
  • 1162293 2024-006
    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) $358,035
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $189,487