Finding 1162475 (2024-006)

Material Weakness Repeat Finding
Requirement
A
Questioned Costs
-
Year
2024
Accepted
2025-11-17

AI Summary

  • Core Issue: HAH failed to keep necessary documentation for services under the Health Centers Program.
  • Impacted Requirements: Compliance with 42 USC 254B was not met, as 3 out of 40 patient files lacked proper documentation.
  • Recommended Follow-Up: Ensure all required information is documented in patient files to strengthen internal controls.

Finding Text

Compliance with Allowable Activities Significant Deficiency U.S DEPARTMENT OF HEALTH AND HUMAN SERVICES ALN #: 93.224 - Health Centers Program and 93.527 - Grants for New and Expanded Services under the Health Center Program Federal Award Identification #: 20H80CS00111, 24H80CS00111, 21H8FCS40976, 23H8GCS47647 Condition: HAH did not retain documentation in support of services provided as part of the Health Centers Program. Criteria: 42 USC 254B Questioned Costs: $0 Context: During the audit, 3 out of 40 patients tested for allowable activities did not have the required documentation for medical services provided. 1 patient did not have a medical service code documented. 2 patients did not have the provider sign off that services were provided and allowable under the grant provisions. Cause: Turnover at HAH, who separated from the parent entity in FY24 resulting in changes in procedures. Effect: Lack of internal control to ensure program requirements are met. Identification as repeat finding, if applicable: Not applicable. Recommendation: We recommend that all required information be documented in patient file. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. See corrective action plan.

Corrective Action Plan

Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now generates and reviews weekly documentation and billing completeness reports to identify and resolve missing or incomplete encounter records. Clinic managers and providers receive weekly follow-ups to ensure that documentation is corrected promptly and that all billed services are properly supported. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved

Categories

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

Other Findings in this Audit

  • 1162455 2024-003
    Material Weakness Repeat
  • 1162456 2024-003
    Material Weakness Repeat
  • 1162457 2024-003
    Material Weakness Repeat
  • 1162458 2024-003
    Material Weakness Repeat
  • 1162459 2024-003
    Material Weakness Repeat
  • 1162460 2024-003
    Material Weakness Repeat
  • 1162461 2024-003
    Material Weakness Repeat
  • 1162462 2024-003
    Material Weakness Repeat
  • 1162463 2024-003
    Material Weakness Repeat
  • 1162464 2024-003
    Material Weakness Repeat
  • 1162465 2024-003
    Material Weakness Repeat
  • 1162466 2024-003
    Material Weakness Repeat
  • 1162467 2024-003
    Material Weakness Repeat
  • 1162468 2024-003
    Material Weakness Repeat
  • 1162469 2024-004
    Material Weakness Repeat
  • 1162470 2024-005
    Material Weakness Repeat
  • 1162471 2024-005
    Material Weakness Repeat
  • 1162472 2024-006
    Material Weakness Repeat
  • 1162473 2024-006
    Material Weakness Repeat
  • 1162474 2024-006
    Material Weakness Repeat
  • 1162476 2024-007
    Material Weakness Repeat
  • 1162477 2024-007
    Material Weakness Repeat
  • 1162478 2024-007
    Material Weakness Repeat
  • 1162479 2024-007
    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) $2.77M
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $683,616
93.323 COVID-19 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $388,539
93.914 HIV EMERGENCY RELIEF PROJECT GRANTS $330,388
93.917 HIV CARE FORMULA GRANTS $259,851
14.241 HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS $129,478
93.116 PROJECT GRANTS AND COOPERATIVE AGREEMENTS FOR TUBERCULOSIS CONTROL PROGRAMS $123,050
93.527 COVID-19 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $122,431
93.924 RYAN WHITE HIV/AIDS DENTAL REIMBURSEMENT AND COMMUNITY BASED DENTAL PARTNERSHIP GRANTS $92,067
93.958 BLOCK GRANTS FOR COMMUNITY MENTAL HEALTH SERVICES $60,545
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $59,855
93.011 COVID-19 NATIONAL ORGANIZATIONS FOR STATE AND LOCAL OFFICIALS $32,939
93.247 ADVANCED NURSING EDUCATION WORKFORCE GRANT PROGRAM $27,280
14.267 CONTINUUM OF CARE PROGRAM $25,361