Finding 1229169 (2025-004)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2025
Accepted
2026-09-09

AI Summary

  • Core Issue: The UDS report and Annual FFR contain inaccuracies due to insufficient review processes.
  • Impacted Requirements: Compliance with reporting standards (45 CFR 75.342) is not met, leading to unreliable patient and funding data.
  • Recommended Follow-up: Implement internal processes and a formal review system to ensure accuracy in reporting for UDS and FFR.

Finding Text

Health Center Program Cluster Assistance Listing 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS26560-12-00 Program Year 2025 Criteria or Specific Requirement: Reporting (45 CFR 75.342) Condition: The Organization’s Uniform Data System (UDS) report did not agree to the underlying support. In addition, certain information in the Organization's Annual Federal Financial Report (FFR) did not agree to underlying support. Cause: The Organization does not properly review the information used in preparing and submitting the UDS report and the FFR. Effect or potential effect: Information provided is incorrect and does not provide accurate counts of patients or federal funds received. Questioned Costs: None Context: Errors and/or inadequate supporting documentation were identified for 3 out of 49 report attributes tested for the Organization's UDS report. Errors and /or inadequate supporting documentation was identified in the Organization's Annual FFR. Identification as a Repeat Finding: Repeat Finding of 2024-004 Recommendation: The Organization should develop internal processes for preparing information that will be reported in the UDS report and the FFR. In addition to this the Organization should develop a formal review process where a reviewer reviews and matches the amount to be reported with the documents used by the preparer.

Corrective Action Plan

Views of Responsible Officials and Planned Corrective Actions: The inconsistencies found in the FFR report were from the report filed in early 2025 prior to the new CFO being hired. The CFO now takes full responsibility for grants management and the associated reporting. Grant records are now being kept in a more accurate and consistent manner, and all required filings are completed timely and in consultation with an external grant consultant when necessary. The 2025 UDS report was prepared with a new process and new staff members. This is an improved structure than previously used, and it will continue to be refined as staff gain more knowledge and experience with the UDS. Staff participate in all available training courses and use a Teams Channel to communicate and share information. The team will perform a final review and ensure that there is supporting documentation that incorporates any follow-up adjustments and agrees to the final UDS report.

Categories

Reporting

Other Findings in this Audit

  • 1229164 2025-003
    Material Weakness Repeat
  • 1229165 2025-003
    Material Weakness Repeat
  • 1229166 2025-003
    Material Weakness Repeat
  • 1229167 2025-004
    Material Weakness Repeat
  • 1229168 2025-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM $400,000
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $46,521
93.778 GRANTS TO STATES FOR MEDICAID $13,157
93.912 RURAL HEALTHCARE SERVICES PROGRAMS $10,000