Finding 1173358 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-02-12

AI Summary

  • Core Issue: Kalihi-Palama Health Center did not consistently calculate sliding fee discounts correctly, leading to potential overcharging of patients.
  • Impacted Requirements: The center failed to comply with federal guidelines for determining discounts based on patients' ability to pay, as outlined by DHHS.
  • Recommended Follow-Up: Implement stronger internal controls to ensure accurate calculations and proper documentation of sliding fee discounts.

Finding Text

Special Tests and Provisions – Sliding Fee Discounts – 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) Grants for New and Expanded Services Under the Health Center Program COVID-19 Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8000814 2025 and 2024, H8L51682 - 2024 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)). Kalihi-Palama Health Center and Subsidiary should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with Kalihi-Palama Health Center and Subsidiary's sliding fee scale. Condition Kalihi-Palama Health Center and Subsidiary did not always calculate the proper sliding fee discount based on approved policies or have adequate documentation on file. Cause Kalihi-Palama Health Center and Subsidiary did not have adequate internal controls in place to effectively ensure that patients received the correct sliding fee discount and have adequate documentation on file. Effect or Potential Effect Kalihi-Palama Health Center and Subsidiary did not comply with the appropriate Special Tests and Provisions rules and regulations as per the Uniform Guidance in 2025. Questioned costs None. Context A test of 40 sliding fee discount transactions was performed and resulted in three instances of incorrect sliding fee calculations, resulting in incorrect fees charged to the patients for their services based on family size and income. Our sample was a statistically valid sample. Identification as a Repeat Finding This finding is not a repeat finding. Recommendation Kalihi-Palama Health Center and Subsidiary 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 Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Corrective Action Plan

Finding 2025.001 Special Tests and Provisions - Sliding Fee Discounts Recommendation Kalihi-Palama Health 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: Effective February 9, 2026, we will implement the following changes to ensure clients are appropriately charged according to the sliding fee scale. -Update the frequency of our sliding fee scale employee training sessions -Implement monthly spot checks to ensure compliance to the sliding fee scale and provide timely feedback

Categories

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

Other Findings in this Audit

  • 1173354 2025-001
    Material Weakness Repeat
  • 1173355 2025-002
    Material Weakness Repeat
  • 1173356 2025-001
    Material Weakness Repeat
  • 1173357 2025-002
    Material Weakness Repeat
  • 1173359 2025-002
    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) $3.16M
14.267 CONTINUUM OF CARE PROGRAM $1.51M
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $1.29M
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $712,315
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $256,158
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $80,000
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $56,937
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $26,586
93.307 MINORITY HEALTH AND HEALTH DISPARITIES RESEARCH $10,000
20.602 OCCUPANT PROTECTION INCENTIVE GRANTS $4,500
10.578 WIC GRANTS TO STATES (WGS) $1,605