Finding Text
Health Center Program Cluster –
ALN Nos. 93.224 and 93.527
U.S. Department of Health and Human Services
Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025
Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024
Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024
Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024
Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024
Criteria or Specific Requirement – Reporting (45 CFR 75.342)
Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases
as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization
double counted certain facility and non-clinical support services costs on the UDS Report.
Cause – The Organization’s pharmacy practice management software was incorrectly set up to
classify certain adjustments as sliding fee discounts and a manual correction was not made during
the preparation of the UDS report. In addition, the Organization’s supporting schedules had
formula errors that causes certain costs to be duplicated.
Effect or potential effect– The Organization overstated sliding fee discounts and overstated the
total costs for facility and non-clinical support services.
Questioned costs – None
Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling
methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS
Report were not accurately reported.
Identification as a repeat finding, if applicable – N/A
Recommendation – Management should review the required reports for accuracy prior to
submission to ensure the documentation supports the amounts in the report.
View of Responsible Officials and Planned Corrective Actions – Management agrees with the
auditors’ recommendations. The UDS formulas were updated and the issues corrected for the
2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant
Management will work together to ensure the accuracy of the UDS Report.
Organization’s contact persons responsible for corrective action: Michele Sarrett
Anticipated completion date: 12/31/2025