Finding 1204668 (2025-003)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-30
Audit: 396440
Organization: Neomed Center, Inc. (PR)

AI Summary

  • Core Issue: NeoMed Center Inc. is not following federal requirements for the sliding fee discount program, leading to potential improper fee discounts and noncompliance risks.
  • Impacted Requirements: Key regulations include 42 CFR §51c.303(f) for fee schedules, 2 CFR §200.303 for internal controls, and HRSA guidelines for eligibility determinations and documentation.
  • Recommended Follow-Up: Improve internal controls, train staff on compliance, standardize monitoring procedures, conduct regular audits, and maintain thorough documentation for eligibility and fee assessments.

Finding Text

Criteria: Health centers receiving federal funding under the Health Center Program (93.224) and Ryan White Part C (93.918) are required to maintain and consistently apply a sliding fee discount program in accordance with federal regulations and program guidance. Specifically, 42 CFR §51c.303(f) requires health centers to have a schedule of fees and discounts based on patients’ ability to pay and to apply the schedule consistently. The HRSA Health Center Program Compliance Manual, Chapter 9, mandates documented eligibility determinations, defined timeframes for eligibility reassessment, proper application of the sliding fee scale, and retention of documentation. Similarly, the Ryan White HIV/AIDS Program Part C Manual requires eligibility determinations and fee assessments consistent with approved policies and program requirements. Additionally, federal standards under 2 CFR §200.303 require non-federal entities to establish and maintain effective internal controls over federal awards, 2 CFR §200.302(b) requires financial management systems to adequately identify and document eligibility determinations, and 2 CFR §200.328 requires accurate programmatic reporting and monitoring. Condition: During testing of the sliding fee discount program for the fiscal year ended June 30, 2025, we identified multiple instances of noncompliance with established policies and federal program requirements. Specifically, patient financial information was updated over prior evaluations, which eliminated historical tracking and resulted in files not being properly closed in accordance with the health center’s policies. Effect: As a result of these deficiencies, NeoMed Center Inc. is at increased risk of improper fee discounts being applied to patients who may not meet eligibility requirements, noncompliance with federal and program-specific requirements, inaccurate financial reporting related to patient service revenue, lack of proper and accurate collection of services provided and potential loss of federal funds awards. Cause: The noncompliance is caused by inadequate implementation of internal controls policies and procedures designed over the sliding fee program. Also, it caused by lack of appropriate staff training and missing standardized monitoring policies and procedures, as well as inadequate supervisory review of eligibility determinations and documentation. Recommendations: We recommend that the Institution implement the following corrective actions: 1. Review current policies and procedures to improve and establish robust internal controls to ensure that patient financial information is updated without overwriting prior evaluations, preserving historical tracking and maintaining properly closed files. 2. Provide training to staff responsible for eligibility determinations and fee assessments to ensure consistent application of the sliding fee scale and compliance with federal program requirements. 3. Implement standardized monitoring and supervisory review procedures to verify that eligibility determinations, fee assessments, and documentation are accurate, complete, and retained in accordance with program requirements. 4. Implement and perform, on a recurrent basis, audit and/or review of patient files to ensure ongoing compliance, timely reassessment, and proper application of the sliding fee discount program. 5. Maintain clear records and documentation to support all eligibility determinations and fee discounts, ensuring the entity can demonstrate compliance during internal reviews or external audit

Corrective Action Plan

Condition: During audit testing of the Sliding Fee Discount Program for the fiscal year ended June 30, 2025, NeoMed Center, Inc. identified deficiencies in the documentation, retention, and supervisory review of patient eligibility determinations. Specifically, patient financial information was updated in a manner that overwrote prior eligibility evaluations, resulting in the loss of historical eligibility records. In addition, patient files were not consistently closed or retained in accordance with established policies and federal program requirements. These conditions reflected weaknesses in internal controls over eligibility documentation and supervisory oversight, which increased the risk of inconsistent application of the sliding fee scale, noncompliance with HRSA Health Center Program and Ryan White Part C requirements, inaccurate patient billing adjustments, and potential misstatement of patient service revenue. Planned Corrective Action: Management implemented corrective actions to strengthen internal controls over the Sliding Fee Discount Program and ensure sustained compliance with applicable federal requirements. Policies and procedures governing eligibility determinations and sliding fee discount applications were revised to require preservation of historical eligibility records, standardized documentation, and proper file‑closure practices. Clear supervisory review responsibilities were established to ensure eligibility determinations and fee assessments are reviewed for accuracy, completeness, and compliance. Targeted training was provided to staff responsible for patient registration, eligibility determinations, and fee assessments to ensure consistent application of the sliding fee scale and adherence to federal program requirements. In addition, management implemented periodic internal reviews of patient files to verify compliance with documentation, retention, and eligibility reassessment requirements, and to promptly identify and remediate any deficiencies. These corrective actions were designed to enhance internal control effectiveness, support accurate financial reporting, and prevent recurrence of the identified condition. Key internal controls include: • Revised and strengthened Sliding Fee Discount Program policies and procedures. • Implemented controls to preserve historical eligibility determinations and documentation. • Established standardized eligibility documentation and file‑closure processes. • Defined supervisory review responsibilities and escalation procedures. • Provided targeted training to eligibility and registration staff. • Implemented periodic internal reviews of patient files to ensure compliance. Monitoring: Management will conduct periodic supervisory reviews of patient eligibility determinations and sliding fee discount applications beginning April 1st, 2026, to ensure compliance with established policies and federal program requirements. Monitoring will include sample testing of patient files to verify proper documentation, preservation of historical eligibility records, and timely reassessments. Results of monitoring activities will be documented and reviewed by management, and corrective actions will be implemented as needed to address any deficiencies identified. Responsible Official: Jose A. Guzman Machuca Time frame: This condition was resolved in March 2026 upon the implementation of revised policies, enhanced documentation controls, staff training, and supervisory review procedures

Categories

Subrecipient Monitoring Eligibility Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1204664 2025-001
    Material Weakness Repeat
  • 1204665 2025-002
    Material Weakness Repeat
  • 1204666 2025-002
    Material Weakness Repeat
  • 1204667 2025-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM $6.96M
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $604,244
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $210,061