Finding 400611 (2023-002)

Significant Deficiency

Requirement

Questioned Costs

Year

2023

Accepted

2024-06-12

Audit: 308666

Organization: Covered Bridge Healthcare of St. Joseph County (MI)

Auditor: Yeo and Yeo PC

AI Summary

Core Issue: The Organization failed to provide necessary support for tables 8 and 9E in the UDS report.
Impacted Requirements: Annual submission of the UDS report is mandatory for health centers.
Recommended Follow-Up: Ensure proper documentation is maintained for all reporting submissions to prevent future issues.

Finding Text

2023-002 – Significant Deficiency and Noncompliance – Reporting Federal Program: Assistance Listing # 93.224 and 93.527, Health Center Program Cluster, Department of Health and Human Services. Criteria: Health centers must prepare and submit their Uniform Data System (UDS) report on an annual basis. Condition: During our review of the Organization’s UDS report, we noted that the Organization was not able to provide support for tables 8 and 9E of the report. Questioned Costs: None Cause: The Organization had turnover in the accounting department in the current year and the former CFO did not properly maintain the supporting schedules for the UDS report. Effect: The Organization may have improperly reported information on its UDS report. Recommendation: We recommend that the Organization maintains documentation for all required reporting submissions. View of Responsible Officials: Management is in agreement with the finding. Corrective Action Plan: See attached corrective action plan.

Corrective Action Plan

Significant changes have been made to how Finance maintains all files and documents to ensure accuracy and integrity of all reports issued by the Finance Department. Specific folders have been set up in the Shared Drive and all members of the Finance Team have appropriate access. These changes were made in February 2024 and are monitored monthly by the Finance Manager and CFO.

Other Findings in this Audit

400612 2023-002

Significant Deficiency
400613 2023-002

Significant Deficiency
400614 2023-002

Significant Deficiency
977053 2023-002

Significant Deficiency
977054 2023-002

Significant Deficiency
977055 2023-002

Significant Deficiency
977056 2023-002

Significant Deficiency

Programs in Audit

ALN	Program Name	Expenditures
93.498	Provider Relief Fund	$251,895
93.527	Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program	$86,887
93.788	Opioid Str	$76,822
93.224	Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care)	$65,500