Finding 384929 (2023-001)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2023
Accepted
2024-03-26

AI Summary

  • Core Issue: The board of directors did not review and approve the 2023 sliding fee scale, violating federal requirements.
  • Impacted Requirements: Compliance with US Code Title 42, which mandates annual review of the sliding fee discount schedule based on patients' ability to pay.
  • Recommended Follow-Up: Ensure the sliding fee scale is consistently added to board meeting agendas for annual review and obtain documented approval before implementation.

Finding Text

Item 2023-001 - Implementation of Sliding Fee Scale Policy: U.S. Department of Health and Human Services, Health Center Program Cluster: Assistance Listing Number 93.224/93.527 - Special Tests and Provisions (Significant Deficiency) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254 b requires Health Centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Community Health Project, Inc.'s policy requires that the board of directors and the Executive Director review the fee structure annually. Statement of Condition: During our audit of the year ended June 30, 2023, we noted that the board of directors did not review and approve the 2023 sliding fee scale. Cause: Due to transition in management, the review of the sliding fee scale was not included among the agenda items for the board meeting. Effect: Failure in implementing one of the internal control procedures over the sliding fee scale may lead to errors and non-compliance of the sliding fee scale to certain federal poverty guidelines. Questioned costs: None Context: The board did not review and approve the sliding fee scale before it was implemented in February 2023. Identification as a repeat finding: This is not a repeat finding. Recommendation: We recommend that management implement their policy that requires board review and approval of the sliding fee scale in a consistent manner. The approval of the sliding fee scale should be added to the agenda items as a recurring annual matter to help ensure that it is completed. We recommend further that the employee/s in charge of inputting the sliding fee scale into the electronic medical record ("EMR") system obtain evidence of board approval of the sliding fee scale before it is coded into the EMR. Management response: Management is in agreement with the audit finding that the sliding fee scale was not presented to the board of directors for review. However, the board reviewed the sliding fee scale during their meeting in February 2024 and did not find any error in the sliding fee scale and they retroactively approved and authorized its application from February 2023 to February 2024. Measures will be taken to ensure that the sliding fee scale is presented on a yearly basis to the board of directors for their review and that such review is documented.

Categories

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 384925 2023-001
    Significant Deficiency
  • 384926 2023-001
    Significant Deficiency
  • 384927 2023-001
    Significant Deficiency
  • 384928 2023-001
    Significant Deficiency
  • 384930 2023-001
    Significant Deficiency
  • 384931 2023-001
    Significant Deficiency
  • 384932 2023-002
    Material Weakness
  • 961367 2023-001
    Significant Deficiency
  • 961368 2023-001
    Significant Deficiency
  • 961369 2023-001
    Significant Deficiency
  • 961370 2023-001
    Significant Deficiency
  • 961371 2023-001
    Significant Deficiency
  • 961372 2023-001
    Significant Deficiency
  • 961373 2023-001
    Significant Deficiency
  • 961374 2023-002
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $1.42M
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $971,070
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $925,530
93.696 Certified Community Behavioral Health Clinic Expansion Grants $664,276
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $639,949
93.944 Human Immunodeficiency Virus (hiv)/acquired Immunodeficiency Virus Syndrome (aids) Surveillance $520,108
93.914 Hiv Emergency Relief Project Grants $498,985
93.686 Ending the Hiv Epidemic: A Plan for America — Ryan White Hiv/aids Program Parts A and B (b) $471,494
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $334,061
93.917 Hiv Care Formula Grants $304,290
93.958 Block Grants for Community Mental Health Services $250,826
93.307 Minority Health and Health Disparities Research $161,144
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $121,176
93.941 Hiv Demonstration, Research, Public and Professional Education Projects $64,434
93.855 Allergy, Immunology and Transplantation Research $60,535
93.829 Section 223 Demonstration Programs to Improve Community Mental Health Services $58,493
93.242 Mental Health Research Grants $44,397
93.865 Child Health and Human Development Extramural Research $14,146