Finding 1181839 (2025-003)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-21

AI Summary

  • Core Issue: The Organization failed to apply the sliding fee scale discount accurately to eligible patients, resulting in overcharges.
  • Impacted Requirements: Compliance with 2 CFR 200.303 and related regulations requiring effective internal controls and proper application of the sliding fee discount.
  • Recommended Follow-up: Ensure consistent and accurate application of the sliding fee scale discount for all eligible patients and monitor improvements in the process.

Finding Text

Assistance Listing, Federal Agency, and Program Name - 93.224, 93.527 - Health Center Program Cluster Federal Award Identification Number and Year - 23H80CS30717, 23H8LCS51933C6, 23H8GCS48653; 2024-2025 Pass through Entity - No Finding Type - Material weakness and material noncompliance with laws and regulations Repeat Finding - No Criteria - Per 2 CFR 200.303 and 42 USC 254b(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g), health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The Organization is responsible for the design, implementation, and maintenance of effective internal control over compliance with the requirements of laws, statutes, regulations, rules, and provisions of contracts or grant agreements applicable to the Organization's federal programs. Condition - During the current year, the Organization did not apply the sliding fee scale discount to certain patient claims accurately. During our testing, we noted 13 instances of the sliding fee scale not being accurately applied to patient services out of the 40 transactions tested. Questioned Costs - None If questioned costs are not determinable, description of why known questioned costs were undetermined or otherwise could not be reported - N/A no questioned costs Identification of How Questioned Costs Were Computed - None Context - During the testing of the sliding fee scale discount, it was noted that 13 of the 40 patient claims tested did not have the sliding fee scale discount properly or consistently applied when the patient was eligible. The Organization was not properly and consistently applying the sliding fee scale discount to patients that were eligible. Cause and Effect - The Organization did not apply the sliding fee scale discount appropriately to the eligible patients. This caused patients to be overcharged for services. Recommendation - The Organization should apply the sliding fee scale discount consistently and accurately to all eligible patients. Views of Responsible Officials and Corrective Action Plan - Management acknowledges the sliding fee scale discount should have been applied consistently and accurately and plan to improve the process going forward. Management corrected the patient accounts by applying the sliding fee scale discount.

Corrective Action Plan

Condition: During the current year, the Organization did not apply the sliding fee scale discount to certain patient claims accurately. During our testing, we noted 13 instances of the sliding fee scale not being accurately applied to patient services out of the 40 transactions tested. Planned Corrective Action: Management acknowledges the sliding fee scale discount should have been applied consistently and accurately and plan to improve the process going forward. Management corrected the patient accounts by applying the sliding fee scale discount. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: June 30, 2026

Categories

Material Weakness Internal Control / Segregation of Duties Special Tests & Provisions

Other Findings in this Audit

  • 1181838 2025-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
21.027 COVID-19 - CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $4.12M
64.033 VA SUPPORTIVE SERVICES FOR VETERAN FAMILIES PROGRAM $2.39M
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $1.69M
93.696 CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINIC EXPANSION GRANTS $1.61M
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $991,962
14.241 HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS $743,417
14.231 EMERGENCY SOLUTIONS GRANT PROGRAM $571,417
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $483,181
93.977 SEXUALLY TRANSMITTED DISEASES (STD) PREVENTION AND CONTROL GRANTS $409,823
14.267 CONTINUUM OF CARE PROGRAM $343,807
93.686 ENDING THE HIV EPIDEMIC: A PLAN FOR AMERICA — RYAN WHITE HIV/AIDS PROGRAM PARTS A AND B $311,865
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $262,240
10.569 EMERGENCY FOOD ASSISTANCE PROGRAM (FOOD COMMODITIES) $260,767
93.667 SOCIAL SERVICES BLOCK GRANT $236,250
64.024 VA HOMELESS PROVIDERS GRANT AND PER DIEM PROGRAM $172,306
10.187 THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) COMMODITY CREDIT CORPORATION ELIGIBLE RECIPIENT FUNDS $149,773
93.940 HIV PREVENTION ACTIVITIES HEALTH DEPARTMENT BASED $149,367
16.575 CRIME VICTIM ASSISTANCE $127,399
16.736 TRANSITIONAL HOUSING ASSISTANCE FOR VICTIMS OF DOMESTIC VIOLENCE, DATING VIOLENCE, STALKING, OR SEXUAL ASSAULT $112,923
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $91,363
97.008 NON-PROFIT SECURITY PROGRAM $90,140
93.788 OPIOID STR $52,181
93.671 FAMILY VIOLENCE PREVENTION AND SERVICES/DOMESTIC VIOLENCE SHELTER AND SUPPORTIVE SERVICES $49,999
93.527 COVID-19 - GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $20,813
97.024 EMERGENCY FOOD AND SHELTER NATIONAL BOARD PROGRAM $17,000
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $14,000
10.565 COMMODITY SUPPLEMENTAL FOOD PROGRAM $11,680
16.588 VIOLENCE AGAINST WOMEN FORMULA GRANTS $8,865
10.182 COVID-19 - PANDEMIC RELIEF ACTIVITIES: LOCAL FOOD PURCHASE AGREEMENTS WITH STATES, TRIBES, AND LOCAL GOVERNMENTS $5,797
10.194 COMMODITY CREDIT CORPORATION (CCC) FUNDING TO ALLEVIATE EMERGENCY SUPPLY CHAIN DISRUPTION IN THE COMMODITY SUPPLEMENTAL FOOD PROGRAM (CSFP) $258