Finding 1162760 (2024-003)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2024
Accepted
2025-11-20
Audit: 372390
Organization: Northshore Health Centers, INC (IN)

AI Summary

  • Core Issue: The Center's reports contained inaccuracies, particularly in the UDS and Federal Financial reports, affecting compliance with federal reporting requirements.
  • Impacted Requirements: Reporting errors included misclassification of visits, understated expenses, and incorrect program income calculations, leading to potential noncompliance.
  • Recommended Follow-Up: Implement a review process by knowledgeable staff to ensure accurate reconciliation of documentation before report submission.

Finding Text

2024-003 Information on the Federal Program: Assistance Listing Number 93.224/93.527; Health Center Program Cluster; Department of Health and Human Services Criteria Or Specific Requirement: Reporting: Health centers must comply with federal reporting requirements. Condition: The Center’s data did not support certain line items reported on the Uniform Data System (UDS) and Federal Financial reports filed. Within Table 5 of the UDS report, the visits reported within column B included both in-person and virtual visits where it should not include virtual visits as those are filed in column b2. Within Table 8A of the UDS report, the amounts reported within line 17 column C, line 1, column C, and line 3, column C, were supported by underlying data, but this information significantly understated expenses compared to audited numbers. Within Table 9E of the UDS report, the amounts reported within line 1Q, column A, included a supplemental grant that should not have had an impact on 2024, but rather 2023. The Federal Financial Report’s calculation of program income was incorrect after comparing to audited numbers and did not include all sources of program income. Cause: Internal controls were not in place to ensure proper reconciliation of the supporting documentation used in the submitted UDS and FFR. Effect or Potential Effect: Inaccurate filing of reports may result in the federal program not being properly monitored, thus resulting in potential noncompliance with program requirements. Questioned Costs: None. Context: Out of a total population of four reports: 1 UDS and 3 Federal Financial reports we tested two reports, the UDS and 1 Federal Financial report. Both tested reports included errors within them. The sample was not statistically valid. Identification as a Repeat Finding, if Applicable: Not a repeat finding. Recommendation: We recommend management implement an additional level of review by an individual with knowledge of the reporting requirements. Views of Responsible Officials and Planned Corrective Actions: Management acknowledged inaccuracies in the FFR and UDS tables that support the report which was filed. In future periods, management will have processes and procedures in place to require reconciliation and tie-out of supporting documentation to each of the final filings prior to submission. The Chief Financial Officer will also perform a formal review of both the FFR and UDS tables and document accordingly.

Corrective Action Plan

Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-003: • NorthShore Health Centers, Inc. acknowledged inaccuracies in the FFR and UDS tables that support the report which was filed. In future periods, management will have processes and procedures in place to require reconciliation and tie-out of supporting documentation to each of the final filings prior to submission. The Chief Financial Officer will also perform a formal review of both the FFR and UDS tables and document accordingly. • Management expects implementation for the December 31, 2025 filings for both the 2025 UDS and FFR

Categories

Reporting

Other Findings in this Audit

  • 1162758 2024-003
    Material Weakness Repeat
  • 1162759 2024-003
    Material Weakness Repeat
  • 1162761 2024-004
    Material Weakness Repeat
  • 1162762 2024-004
    Material Weakness Repeat
  • 1162763 2024-004
    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) $5.68M
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $158,578
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $149,714
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $75,000
93.426 THE NATIONAL CARDIOVASCULAR HEALTH PROGRAM $55,000