Finding 1182217 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-24

AI Summary

  • Core Issue: The Organization failed to maintain proper documentation and internal controls for sliding fee scale discounts, leading to incorrect calculations.
  • Impacted Requirements: Non-compliance with federal guidelines regarding patient eligibility and discount calculations under the Health Center Program.
  • Recommended Follow-Up: Implement stronger internal controls and monitoring systems to ensure accurate calculation and documentation of sliding fee discounts.

Finding Text

Finding 2025.001: Special Tests and Provisions - Sliding Fee Scale Discounts - Significant Deficiency Name of Federal Agency: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Health Center Program, 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: H80CS00841 - 2024 and 2025, H8KCS49808 - 2024 and 2025, H8HCS46177 - 2025, H8NCS53918 - 2025, H8LCS50858 - 2024, H8JCS54606 - 2025 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)). The Organization should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Organization's sliding fee scale. Condition The Organization did not always have the proper slide fee documentation readily available to ensure the proper slide fee discount was applied based on approved policies or the discount was calculated incorrectly. Cause The Organization did not have adequate internal controls in place to effectively ensure that all sliding fee discounts were properly calculated based on approved documentation. Effect or Potential Effect The Organization did not comply with the appropriate Special Tests and Provisions rules and regulations as per the Uniform Guidance in 2025. Questioned Costs NoneContext A test of 40 sliding fee discount transactions was performed and resulted in four instances where the sliding fee discount was calculated incorrectly. Our sample was a statistically valid sample. Identification of Repeat Finding This finding is not a repeat finding. Recommendation The Organization 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 and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency. Management has prepared a Corrective Action Plan that outlines the additional controls implemented.

Corrective Action Plan

Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization 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 Staff Training Quality Assurance and Monitoring To ensure sustained compliance, the organization is implementing the following monitoring process: • Monthly random chart audits of sliding fee documentation. • Minimum sample size of 40 patient records • Audit elements will include: o Income documentation present o Household size documented o Correct FPG calculation o Correct discount level applied • Findings will be reported to senior leadership and the compliance committee. Corrective coaching is provided when deficiencies are identified. Comprehensive training is being conducted for all relevant staff including: • Patient access / front desk staff • Financial counselors • Billing staff • Site managers Training topics include: • HRSA Sliding Fee Discount Program requirements • Determining household size • Calculating FPG percentage • Acceptable income documentation • Proper EHR documentation • Self-attestation procedures

Categories

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

Other Findings in this Audit

  • 1182215 2025-001
    Material Weakness Repeat
  • 1182216 2025-001
    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) $9.54M
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $1.43M
93.354 PUBLIC HEALTH EMERGENCY RESPONSE: COOPERATIVE AGREEMENT FOR EMERGENCY RESPONSE: PUBLIC HEALTH CRISIS RESPONSE $440,615
93.247 ADVANCED NURSING EDUCATION WORKFORCE GRANT PROGRAM $316,978
93.493 CONGRESSIONAL DIRECTIVES $312,706
93.332 COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED EXCHANGES $157,715
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $150,000
20.509 FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM $113,370
16.738 EDWARD BYRNE MEMORIAL JUSTICE ASSISTANCE GRANT PROGRAM $73,240
16.585 TREATMENT COURT DISCRETIONARY GRANT PROGRAM $67,595
93.211 TELEHEALTH PROGRAMS $58,400
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $54,819
93.071 MEDICARE ENROLLMENT ASSISTANCE PROGRAM $50,000
93.917 HIV CARE FORMULA GRANTS $46,995
93.767 CHILDREN'S HEALTH INSURANCE PROGRAM $43,163
93.387 NATIONAL AND STATE TOBACCO CONTROL PROGRAM $29,797
93.778 MEDICAL ASSISTANCE PROGRAM $26,788
93.366 STATE ACTIONS TO IMPROVE ORAL HEALTH OUTCOMES AND PARTNER ACTIONS TO IMPROVE ORAL HEALTH OUTCOMES $16,000
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $13,851
93.884 PRIMARY CARE TRAINING AND ENHANCEMENT $11,200
93.191 GRADUATE PSYCHOLOGY EDUCATION $1,620