Finding 1166259 (2025-002)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2025
Accepted
2025-12-23
Audit: 377319

AI Summary

  • Core Issue: The Organization misclassified pharmacy purchase adjustments as sliding fee discounts and double counted certain costs on the UDS report.
  • Impacted Requirements: Reporting standards under 45 CFR 75.342 were not met, leading to inaccurate financial reporting.
  • Recommended Follow-Up: Management should ensure accuracy in reports before submission, with new leadership overseeing corrections by 2/15/2026.

Finding Text

Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2025 - March 31, 2026 Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 6 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – 2024-002 Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett, Chief Financial Officer Anticipated completion date: 2/15/2026

Corrective Action Plan

Management agrees with the auditors' recommendations. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization contact persons responsible for corrective action: Michele Sarrett, Chief Financial Officer. Anticipated completion date: 2/15/26

Categories

Procurement, Suspension & Debarment HUD Housing Programs Reporting

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) $2.92M
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $237,500
93.965 COAL MINERS RESPIRATORY IMPAIRMENT TREATMENT CLINICS AND SERVICES $227,306
93.493 CONGRESSIONAL DIRECTIVES $136,380
93.788 OPIOID STR $91,845
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $83,000
93.912 RURAL HEALTH CARE SERVICES OUTREACH, RURAL HEALTH NETWORK DEVELOPMENT AND SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT $60,000
93.859 BIOMEDICAL RESEARCH AND RESEARCH TRAINING $30,000
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $29,375
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $20,000
93.778 MEDICAL ASSISTANCE PROGRAM $7,500
93.590 COMMUNITY-BASED CHILD ABUSE PREVENTION GRANTS $2,006