Finding Text
Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 - (Significant Deficiency) Criteria: Per 2 CFR §200.303(d), non-Federal entities must take prompt action when instances of noncompliance are identified, including those found in audits and monitoring reviews. Entities are also required to establish and maintain effective internal control over federal awards, including monitoring and corrective action systems. Statement of Condition: During our audit, we noted that LBUCC conducted quarterly internal audit reviews of fifty (50) samples self-pay patients to review for sliding fee discount determination. However, we noted that the findings or exceptions identified in the quarterly internal audit review remained uncorrected. Cause: LBUCC did not have a formal tracking and follow-up procedure to ensure that internal audit findings are remediated in a timely and effective manner. Effect: Lack of procedures to track and follow up the remediation of detected errors increases the risk that errors may persist and may lead to noncompliance and/or financial reporting errors. Questioned Costs: None Context: LBUCC’s Operating Data Analyst haphazardly selects 50 samples from the sliding fee visits each quarter, inspects the supporting documentations and reviews the annual income calculation and sliding fee determination. The Operating Data Analyst noted 16 and 25 exceptions during the 3rd and 4th quarter internal reviews and none of these exceptions were communicated to the respective department and therefore all exceptions remained uncorrected. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend that LBUCC establish a process for communicating, investigating and correcting all internal audit findings or exceptions on a timely manner. Additionally, we recommend that management identify the potential cause of such findings or exceptions and that necessary corrective actions be taken to address such cause. For example, LBUCC may conduct periodic training of all employees involved in the patient intake and screening process. Management Response: Management agrees with the finding and will implement these steps to strengthen our internal controls particularly the monitoring component as this is essential for sustaining compliance