Finding Text
2025-004 Reporting (repeat of finding 2024-004) Program Information Federal Agency U.S. Department of Health and Human Services Assistance Listing Numbers 93.224 Health Centers Program Cluster Award Numbers H80CS00055, H8GCS48089 Criteria Based on the standards of documentation of Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Subpart D requires the Clinic to retain adequate records and other supporting documentation for reports submitted to awarding agencies under the compliance requirements for reporting. [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition The Clinic did not maintain sufficient supporting records for the information reported in its calendar year 2024 Uniform Data System (UDS) report. This finding appears to be an isolated incident. Cause The Clinic’s internal controls over compliance did not include adequate controls over the retention of supporting documentation for UDS reports submitted to awarding agencies. Effect The Clinic submitted UDS reports for federal awards that may lack supporting documentation. Amounts reported may not be correct. Questioned Costs None identified. Context Amounts reported in Table 4: Selected Patient Characteristics, Income as a Percent of Poverty Guidelines, Universal Report, Line 6 Column a, Table 5: Staffing and Utilization, Line 8, Column b (clinic visits) and b2 (virtual visits), Table 5: Staffing and Utilization, Line 10a, Column b (clinic visits) and b2 (virtual visits), and Table 8A: Financial Costs Line 17 Column c, Table 8A: Financial Costs, Line 1, Column C and Table 8A, Line 3, Column C did not agree to the supporting documentation. Recommendation We recommend the Clinic maintain documentation supporting reports filed with awarding agencies. If changes to the reported amounts are made, the supporting documentation should be updated and the reason for the change should be documented. Views of responsible officials and planned corrective action White Bird Clinic agrees with this finding. White Bird Clinic had to switch EHRs during 2023 and 2024, which required our Dental, Medical, and Behavioral Health programs to use their own separate EHR to alleviate critical functional and capacity deficiencies that were caused by our previous EHR. This resulted in significantly more complexity when calculating our UDS numbers. The process involved combining all of our patient demographics and accounting for overlapping (duplicate encounters) by hand. This was made all the more difficult by name misspellings and other errors during data entry. Relating to our prior year finding, White Bird Clinic had contracted with a third party to implement a custom population health tool to automate our UDS reporting. The contractor did not meet specified deliverable requirements, so reporting was again done manually, which resulted in the errors. White Bird Clinic has been working to evaluate population health tools to aggregate patient data to provide more accurate UDS and clinical quality reporting. In 2026, through the help of our HCCN, Health Efficient, we contracted with Relevant Health to implement their population health tool to streamline and accurately report our population health and our UDS reporting. The Relevant platform is in use by over 100 FQHCs across the country. This tool will aggregate patient data from each EHR, account for duplicates, and accurately report combined UDS demographics from all our systems. They are very experienced with UDS and UDS+ reporting, so the system is designed to seamlessly provide accurate and consistent UDS metrics and address duplicate clients from multiple EHRs.