Finding Text
Criteria: Federal regulations require non-federal entities to maintain records that adequately support federal program reporting. Specifically, 2 CFR 200.302 requires recipients to maintain financial and programmatic records that provide accurate, current, and complete disclosure of program results, and 2 CFR 200.333 requires records to be retained and available for audit. HRSA Health Center Program requirements further require health centers to maintain documentation supporting data reported in the Uniform Data System (UDS), including patient-level records supporting Table 4 – Selected Patient Characteristics. Condition: The health center did not provide a report or reconciliation that ties source data to the totals reported in UDS Table 4 – Selected Patient Characteristics. Management provided a report based on billable visits and patients only, which excluded visits and patients for which no charge was associated. Management stated that UDS data are pulled directly from the electronic health record system (eClinicalWorks) by the compliance department using system mapping that differs from billing reports, and that the mapping will not change. As a result, the auditors were unable to verify that all patients required to be included in Table 4 were captured and accurately reported. Cause: The health center did not have documentation available to validate the accuracy and completeness of the UDS Table 4 data. Effect: Because a reconciliation or alternative audit trail was not available, the auditors were unable to determine whether UDS Table 4 data were complete and accurate, including whether non-billable patients were appropriately included. This condition increases the risk that the UDS report contains incomplete or inaccurate patient characteristic data, which may affect HRSA’s oversight, monitoring, and funding determinations. Questioned Costs: No questioned costs are reported for this finding, as the UDS report represents programmatic reporting and does not directly result in identifiable questioned costs. Recommendation: We recommend that management establish and document controls over UDS reporting, including developing reconciliations or alternative audit trails that demonstrate completeness of patient populations reported in Table 4, documenting system mapping and logic used to generate UDS data, and implementing management review procedures prior to UDS submission.