For the 2023 Uniform Data System (UDS) report, the data was compiled using information from two different Electronic Medical Record (EMR) systems. Due to this system fragmentation, there were reporting shortfalls, and the organization relied on historical data estimates to ensure timely submission of the report. These estimates were used to comply with the UDS submission requirements, despite the data not being fully supported by direct system generated reports. For the 2024 UDS report, the organization transitioned to a single EMR
system, which has significantly improved the accuracy and completeness of the data. All reported amounts for the 2024 UDS submission are now fully supported by backup data directly generated from the unified EMR system. It is important to note that the Health Resources and Services Administration (HRSA) has consistently approved the organization’s Federal Financial Report (FFR) submissions without including program income, and as such, the organization was not aware of a potential noncompliance issue related to this omission. Going forward, the organization’s Uniform Data System (UDS) reports will be consistent and based on data extracted from a single, unified Electronic Medical Record (EMR) system. This transition ensures greater accuracy and completeness in reporting, with all future UDS reports supported by direct system-generated data. Additionally, the organization will begin reporting program income on the Federal Financial Report (FFR) as part of ongoing improvements to ensure full compliance with reporting requirements. It is important to note that the current FFR report was approved by the Health Resources and Services Administration (HRSA) without program income listed, and this omission was not previously identified as a noncompliance issue. The organization is committed to maintaining transparent and accurate reporting in the future, and steps are being taken to ensure that all required data, including program income, is properly reflected in all relevant reports. This is the responsibility of the QI department and the CFO and will be complete following the next filing of the FFR and UDS.