Finding 1176657 (2024-003)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2026-03-05
Audit: 390525
Organization: Harrington Family Health Center (ME)

AI Summary

  • Core Issue: There is a significant deficiency in internal controls over compliance related to the sliding fee discount program, leading to inconsistent application of discounts.
  • Impacted Requirements: The Organization must comply with federal requirements for sliding fee discounts based on patient ability to pay, as outlined in the Public Health Services Act.
  • Recommended Follow-Up: Establish a formal monitoring procedure for discount applications, including responsibilities, review frequency, and supervisory oversight to ensure compliance and accuracy.

Finding Text

Finding Number: 2024-003 Finding Type: Significant Deficiency in Internal Controls Over Compliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (93.527) Grant Award: 5 H80CS00802-22 Budget Period: April 1, 2023 through March 31, 2024 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which patient charges are adjusted based on the patient’s ability to pay. Condition: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $115 but qualified for a discount of $215, resulting in a $100 difference. Cause: The application of sliding fee discounts to patient accounts involves manual processes, which are inherently susceptible to errors. The Organization does not currently have a formal monitoring process or policy to ensure discounts are applied correctly, which increases the risk that errors may occur and go undetected. Effect: It is possible that sliding fee discounts may not be applied consistently across all patient accounts, and errors may not be identified and corrected in a timely manner, which could result in noncompliance with the Organization’s sliding fee discount program and federal program requirements. Questioned Costs: None Repeat Finding: No Recommendation: The Organization should establish a formal procedure to monitor compliance with its sliding fee discount program. The procedure should assign responsibility for reviewing applied discounts, define the frequency and sample size of reviews, and include consideration for differences between the Medical and Dental systems, with a larger or more frequent sample for Dental due to higher manual processing and volume. The procedure should also include steps to document and correct any errors identified and require supervisory oversight to verify that reviews are performed consistently. Implementing this procedure will help ensure discounts are applied accurately and in accordance with the Organization’s policy and federal requirements. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will develop and implement the recommendations above.

Corrective Action Plan

Finding: 2024-003 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $115 but qualified for a discount of $215, resulting in a $100 difference. Individual(s) Responsible for Corrective Action: Tafta McCain, Interim CEO, Fraction CFO – Community Link Consulting, Financial Team Planned Corrective Action: The Organization has revised its sliding fee discount policies and has established controls that streamline the path of sliding fee documentation from time of receipt to patient notification in a spreadsheet shared between front office, financial and billing staff. All pertinent documents are uploaded and hyperlinked to the spreadsheet for easy reference. The corrective action includes implementing quarterly supervisory reviews of sliding fee discounts, defining a sample size, and documenting corrective actions when errors are identified. Additional attention will be given to areas with greater manual processing, including Dental services. Staff training has been reinforced to ensure understanding of policy requirements, and management oversight will verify that monitoring procedures are performed consistently and documented appropriately. These actions will strengthen compliance with Section 330 requirements and reduce the risk of future inconsistencies. Anticipated Completion Date: Document tracking is in progress with quarterly review to begin in April 2026.

Categories

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Other Findings in this Audit

  • 1176652 2024-002
    Material Weakness Repeat
  • 1176653 2024-002
    Material Weakness Repeat
  • 1176654 2024-002
    Material Weakness Repeat
  • 1176655 2024-002
    Material Weakness Repeat
  • 1176656 2024-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $450,844
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $328,547
10.766 COMMUNITY FACILITIES LOANS AND GRANTS $286,270
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $5,311