Finding 1226432 (2025-005)

Material Weakness Repeat Finding
Requirement
P
Questioned Costs
-
Year
2025
Accepted
2026-08-13

AI Summary

  • Core Issue: The governing board lacks the required 51% patient representation, with only 50% of members qualifying as patient board members.
  • Impacted Requirements: Three out of six identified patient board members did not receive qualifying services within the last 24 months, failing to meet HRSA definitions.
  • Recommended Follow-up: Increase patient board member count to at least 7 and ensure all members have received qualifying services within the required timeframe.

Finding Text

Criteria – As per the HRSA compliance manual, the health center requires that at least 51 percent of governing board members be patients of the health center. A patient board member must have received at least one service within the preceding 24 months that generated a health center visit, where both the service and the site were within the HRSA-approved scope of project. Condition and Description – During our testing of the composition of the governing board, we noted that only 6 of the 12 governing board members (50%) were identified as patient board members. To satisfy the Health Center Program requirement that at least 51% of governing board members be patients of the health center, a minimum of 7 of the 12 board members were required to meet the patient board member definition. Additionally, testing revealed that 3 of the 6 board members identified as patient board members did not receive at least one service within the preceding 24 months that generated a health center visit, where both the service and the site were within the HRSA-approved scope of project. As a result, these individuals did not meet the Health Center Program definition of a patient board member. Consequently, the Agency did not maintain a governing board with at least 51% patient representation as required by HRSA. Cause/Effect – The Agency has not complied with the requirements for maintaining a governing board with at least 51% patient representation and including receipt of qualifying services within the preceding 24 months

Corrective Action Plan

We concur with the finding. There are currently 11 Board members and 6 are consumer members and the one member has subsequently been seen in the clinic. As a result, we believe we are currently in compliance with this requirement.

Categories

No categories assigned yet.

Other Findings in this Audit

  • 1226429 2025-004
    Material Weakness Repeat
  • 1226430 2025-005
    Material Weakness Repeat
  • 1226431 2025-005
    Material Weakness Repeat
  • 1226433 2025-006
    Material Weakness Repeat
  • 1226434 2025-006
    Material Weakness Repeat
  • 1226435 2025-006
    Material Weakness Repeat
  • 1226436 2025-006
    Material Weakness Repeat
  • 1226437 2025-006
    Material Weakness Repeat
  • 1226438 2025-006
    Material Weakness Repeat
  • 1226439 2025-006
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.926 HEALTHY START INITIATIVE $1.08M
93.224 HEALTH CENTER PROGRAM $460,071
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $457,517
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $59,394
93.436 WELL-INTEGRATED SCREENING AND EVALUATION FOR WOMEN ACROSS THE NATION (WISEWOMAN) $10,250
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $10,000