Finding 1225492 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-07-31

AI Summary

  • Core Issue: There is a significant deficiency in internal controls regarding the sliding fee discount schedule, leading to incorrect patient eligibility determinations.
  • Impacted Requirements: Compliance with 42 USC 254b and 42 CFR sections regarding the sliding fee discount schedule is not being met, as eligibility is incorrectly based on net income instead of gross income.
  • Recommended Follow-Up: Management should review and update the sliding fee policy, ensure staff are trained on it, and establish a secondary review process to prevent future errors.

Finding Text

Federal Agency: U.S Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Number: 93.224 and 93.527 Award Period: 03/1/24-02/28/27 Type of Finding: Significant Deficiency in Internal Control over Compliance and Compliance Criteria or specific requirement: Per 42 USC 254b(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e),(f), and (g); the health and 42 CFR sections 56.303(e), (f), and (g) a health center must establish and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: Per La Pine Community Health Center’s sliding fee discount policy the determination of a patient’s eligibility for the program is determined based upon gross income. Context: During our testing of the sliding fee discount program, we identified six instances of 40 that were determined based upon a patient’s net income vs gross income. Cause: Process and procedures were not followed and the Organization’s internal control system failed to identify the wrong basis for program eligibility was used in the determination process. Effect: Potentially a patient would receive an incorrect determination and/or sliding fee discount. Recommendation: Management should review their sliding fee policy, refamiliarize personnel with the policy, and implement a secondary review process. Views of responsible officials: There is no disagreement with the audit finding.

Corrective Action Plan

Action taken in response to finding: The organization has worked with appropriate staff to provide further clarification on sliding fee intake and approval process.

Categories

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1225491 2025-001
    Material Weakness Repeat
  • 1225493 2025-002
    Material Weakness Repeat
  • 1225494 2025-002
    Material Weakness Repeat
  • 1225495 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.766 COMMUNITY FACILITIES LOANS AND GRANTS $5.09M
93.493 CONGRESSIONAL DIRECTIVES $2.08M
93.224 HEALTH CENTER PROGRAM $1.53M
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $33,265