Finding 1223572 (2025-002)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-07-13

AI Summary

  • Core Issue: Incorrect application of sliding fee discounts for 2 out of 40 patient accounts due to inadequate internal controls.
  • Impacted Requirements: HRSA mandates that discounts be based on complete income documentation; patients without sufficient information should not receive discounts.
  • Recommended Follow-Up: Establish a secondary review process, conduct periodic tests of fee determinations, and provide staff training on SFDP requirements.

Finding Text

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Number: 93.224 Federal Award Identification Number and Year: H8029021 Award Period: June 1, 2024 - May 31, 2027 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Criteria or specific requirement: The Health Resources and Services Administration (HRSA), as reflected in the OMB Compliance Supplement for the Health Center Program, requires health centers to maintain and consistently apply a sliding fee discount program (SFDP) based on patients’ documented household income and family size. Discounts must be determined using current, complete applications with supporting documentation, and applied in accordance with the approved sliding fee schedule. Patients who do not provide sufficient income information are not eligible for sliding fee discounts. Condition: The Organization applied a sliding fee adjustment incorrectly to 2 of 40 patient accounts tested. Questioned costs: None Context: In a sample of 40: • One instance was noted where the discount level applied (e.g., Slide A) did not align with the sliding fee application income reported, which supported a different discount eligibility (e.g., Slide B). • One instance was noted where a sliding fee discount was applied to a patient's balance, however, a sliding fee application was not received from the patient. Cause: The noncompliance appears to result from inadequate internal controls over the review and approval of sliding fee applications, including: • Insufficient verification of income documentation prior to assigning discount levels • Lack of a control to ensure a completed application is on file before applying discounts • Inconsistent application of policies by staff responsible for patient eligibility determinations Effect: Patients may have received discounts that were not in accordance with HRSA requirements. Repeat Finding: No Recommendation: We recommend the following controls be put into place: • Implement a secondary review or approval control to validate that assigned discount levels align with documented income • Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule • Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards Views of responsible officials: Management agrees with the above finding and has since implemented an additional review of all sliding fee applications received and additional training for intake staff.

Corrective Action Plan

Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026

Categories

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Programs in Audit

ALN Program Name Expenditures
10.766 COMMUNITY FACILITIES LOANS AND GRANTS $2.01M
93.224 HEALTH CENTER PROGRAM $1.18M