Finding 1225392 (2025-003)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-07-31
Audit: 408346
Organization: Harrington Family Health Center (ME)

AI Summary

  • Core Issue: There is a significant deficiency in internal controls regarding the Sliding Fee Discount Program, leading to missing eligibility documentation for discounts applied to patients.
  • Impacted Requirements: Compliance with Section 330(k)(3)(G) of the Public Health Services Act is at risk, as the organization cannot prove discounts were applied correctly.
  • Recommended Follow-Up: Management should enhance controls to ensure eligibility documentation is collected and maintained before discounts are applied and regularly monitor patient files for compliance.

Finding Text

Finding Number: 2025 003 Finding Type: Significant Deficiency in Internal Controls over Compliance related to Special Tests and Provisions and Noncompliance Information on the Federal Program: Program Name: Health Center Program Cluster (93.224) Grant Award: H80CS00802 Budget Period: April 1, 2024 through March 31, 2025 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which patient charges are adjusted based on the patient’s ability to pay. Condition: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was applied. Cause: Controls over the Sliding Fee Discount Program did not consistently ensure that eligibility documentation was obtained and maintained prior to application of discounts. A similar compliance issue was identified in prior year Finding 2024-003; however, corrective actions could not be implemented during the current audit period due to the timing of issuance of the prior year audit report. Effect: Without documented eligibility at the time discounts were applied, the Organization cannot demonstrate that sliding fee discounts were properly supported in accordance with Health Center Program requirements. Questioned Costs: None Repeat Finding: Yes, 2024-003 Recommendation: Management should strengthen controls over the Sliding Fee Discount Program to help ensure eligibility documentation is obtained, documented, and maintained prior to the application of discounted charges. Management should also reinforce procedures for timely completion and retention of eligibility determinations and periodically monitor patient files for completeness. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will implement procedures to ensure sliding fee discount eligibility is documented and maintained prior to application of discounted charges and will strengthen monitoring of eligibility determinations and renewal requirements.

Corrective Action Plan

Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was applied Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Billing Team Planned Corrective Action: The Organization revised its sliding fee discount policies, implemented centralized documentation tracking, and enhanced staff training related to eligibility determination and documentation requirements. Monitoring procedures, including periodic supervisory review, were established to ensure compliance. Anticipated Completion Date: Implemented and in progress. Due to the timing of the prior year’s audit completion, the Organization did not have time to complete a full monitoring cycle prior to audit testing.

Categories

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

Other Findings in this Audit

  • 1225389 2025-002
    Material Weakness Repeat
  • 1225390 2025-002
    Material Weakness Repeat
  • 1225391 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM $1.33M
10.766 COMMUNITY FACILITIES LOANS AND GRANTS $232,860
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $31,322