Finding 2025-003 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing the Federal Poverty Guideline (FPG), thirteen files did not contain verification that the patient had no income. Also, 5 files did not contain evidence of review by the Health Center’s staff. Action Planned in Response to the Finding: In 2025, the collection and retention of sliding fee discount qualifying documents were integrated and the calculation performed by the clinic’s electronic medical record system so the prior paper system of documentation was replaced by the EMR’s audit trail reporting. Since HRSA chapter 9 Demonstrating Compliance section G states patients refusing to provide income or family size is an exception to the need for records, this input cell was left blank. Going forward, if a patient declines to provide proof requested, we will request patient sign a form and will add a comment that patient declines to provide this information. To address the evidence of review issue, this was a potential issue when we had the paper process but now that we are electronic, all access to determine sliding fee discount is captured with name of employee and a time stamp. Official Responsible for Ensuring the CAP: Darian Davis Planned Completion Date: December 2026