Finding 1174053 (2024-004)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2024
Accepted
2026-02-17

AI Summary

  • Core Issue: The UDS report has discrepancies with the underlying data due to inadequate review processes.
  • Impacted Requirements: Compliance with reporting standards (45 CFR 75.342) is not met, leading to inaccurate patient and funding counts.
  • Recommended Follow-Up: Establish internal processes and a formal review system to ensure accurate data preparation and reporting for the UDS.

Finding Text

Health Center Program Cluster Assistance Listing 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS26560-11-00 Program Year 2024 Criteria or Specific Requirement: Reporting (45 CFR 75.342) Condition: The Organization’s Uniform Data System (UDS) report did not agree to the underlying support. Cause: The Organization does not properly review the information used in preparing and submitting the UDS report. Effect or potential effect: Information provided is incorrect and does not provide accurate counts of patients or federal funds received. Questioned Costs: None Context: Errors and/or inadequate supporting documentation were identified for 9 our of 49 report attributes tested for the Organization's UDS report. Identification as a Repeat Finding: Not a repeat finding. Recommendation: The Organization should develop internal processes for preparing information that will be reported in the UDS report. In addition to this the Organization should develop a formal review process where a reviewer reviews and matches the amount to be reported with the documents used by the preparer.

Corrective Action Plan

Views of Responsible Officials and Planned Corrective Actions: Due to staff turnover, there were inconsistent methods used to compile data for the UDS reporting and appropriate documentation was not maintained. This will be rectified by the addition of management staff to oversee and facilitate this process. A group of staff have been assembled and assigned certain tasks related to the reporting. This group meets and communicates on a regular basis to ensure completion and compliance with all requirements. A structure has also been established in Teams to track progress and be a repository for documents and communication. The final report will be reviewed and submitted by February 15, 2026.

Categories

Reporting

Other Findings in this Audit

  • 1174046 2024-003
    Material Weakness Repeat
  • 1174047 2024-003
    Material Weakness Repeat
  • 1174048 2024-003
    Material Weakness Repeat
  • 1174049 2024-003
    Material Weakness Repeat
  • 1174050 2024-004
    Material Weakness Repeat
  • 1174051 2024-004
    Material Weakness Repeat
  • 1174052 2024-004
    Material Weakness Repeat
  • 1174054 2024-005
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $240,000
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $200,000
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $189,062
93.778 MEDICAL ASSISTANCE PROGRAM $48,873
93.332 COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED EXCHANGES $19,806