March 15, 2024
Health Resources and Services Administration
Patrick McGovern, Community Health Project, Inc.’s (d/b/a Michael Callen-Audre Lorde Community
Health Center’s) CEO respectfully submits the following corrective action plan for the year ended June
30, 2023:
CohnReznick LLP
1301 Avenue of the Americas
New York, NY 10019
Audit Period: June 30, 2023
The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The
findings are numbered consistently with the numbers assigned in the schedule.
FINDINGS FEDERAL AWARD PROGRAM AUDITS
Material Weakness
2023-002 - Accuracy of Reporting to the PRF Portal: U.S. Department of Health and Human Services,
COVID-19: Provider Relief Fund and American Rescue Plan ("ARP") Rural Distribution: Assistance Listing
Number 93.498 – Reporting
Recommendation
We recommend that the Organization strengthen its system of internal controls to ensure that all
reporting that is done and submitted is consistent with requirements and instructions as
provided by regulatory agencies.
Action Taken
The Organization has implemented policies and procedure to ensure controls are implemented to review
against underlying documentation prior to submission to ensure compliance with regulatory agencies.
Significant Deficiency
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
Chelsea
356 West 18th Street
New York, NY 10011
212.271.7200
Thea Spyer Center
230 West 17th St
New York, NY 10011
212.271.7200
Bronx
3144 3rd Ave
Bronx, NY 10451
718.215.1800
Recommendation
We recommend that management implement their policy that requires board review 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.
Action Taken
The organization has implemented an annual approval process for the sliding fee scale to be added as an
agenda item for our board approval within the first quarter of every calendar year. For the 2023 sliding fee
scale, the board subsequently performed its review and did not find any errors with it thus they retroactively
approved and authorized its application We have implemented a procedure whereby the billing department
in charge shall seek to obtain this approval annually.
Sincerely yours,
Signature:
Name: Patrick McGovern
Title: Chief Executive Officer
Organization’s Name: Callen-Lorde Community Health Center
Date: 3/15/2024